Provider Demographics
NPI:1114789658
Name:BLACK, WILMALEAN MICHELLE (MEDICAL EXAMINER)
Entity Type:Individual
Prefix:MS
First Name:WILMALEAN
Middle Name:MICHELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:MEDICAL EXAMINER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2506 39TH ST APT 68
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-3887
Mailing Address - Country:US
Mailing Address - Phone:601-850-1012
Mailing Address - Fax:
Practice Address - Street 1:2506 39TH ST APT 68
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39305-3887
Practice Address - Country:US
Practice Address - Phone:601-850-1012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty