Provider Demographics
NPI:1144794280
Name:BLACK, HAYLEE SAMANTHA
Entity Type:Individual
Prefix:
First Name:HAYLEE
Middle Name:SAMANTHA
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 1:147 TIBTON CIR
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-1266
Mailing Address - Country:US
Mailing Address - Phone:843-467-7946
Mailing Address - Fax:
Practice Address - Street 1:147 TIBTON CIR
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-1266
Practice Address - Country:US
Practice Address - Phone:843-467-7946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2019-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program