Provider Demographics
NPI:1083982045
Name:BLACK, TINA
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 796
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-0069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:210 SPARKS DR
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-1818
Practice Address - Country:US
Practice Address - Phone:360-431-8275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-06
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula