Provider Demographics
NPI:1093079998
Name:BLACK, ANDREA RENEE (APRN)
Entity Type:Individual
Prefix:MRS
First Name:ANDREA
Middle Name:RENEE
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5590 KIETZKE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3019
Mailing Address - Country:US
Mailing Address - Phone:775-323-2080
Mailing Address - Fax:775-323-2334
Practice Address - Street 1:5590 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-3019
Practice Address - Country:US
Practice Address - Phone:775-323-2080
Practice Address - Fax:775-683-9404
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN001395363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1093079998Medicaid
NV1093079998Medicaid