Provider Demographics
NPI:1205011715
Name:BLACK, GLADYS E (APRN)
Entity Type:Individual
Prefix:MRS
First Name:GLADYS
Middle Name:E
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 1:330 NORTH WABASH
Mailing Address - Street 2:SUITE G20
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46952-2600
Mailing Address - Country:US
Mailing Address - Phone:765-660-7600
Mailing Address - Fax:765-651-7313
Practice Address - Street 1:441 N WABASH AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46952-2612
Practice Address - Country:US
Practice Address - Phone:765-660-6411
Practice Address - Fax:765-651-7313
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002475Z208M00000X
IN71002475A363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200982170Medicaid
IN000000645919OtherANTHEM
IN227300DMedicare PIN
IN000000645919OtherANTHEM