Provider Demographics
NPI:1205194875
Name:BLACK, ELIZABETH (NP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 WARRENVILLE RD
Mailing Address - Street 2:280
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1748
Mailing Address - Country:US
Mailing Address - Phone:630-324-7900
Mailing Address - Fax:
Practice Address - Street 1:2650 WARRENVILLE RD
Practice Address - Street 2:280
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1748
Practice Address - Country:US
Practice Address - Phone:630-324-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-02
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003918A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71003918AOtherRN LICENSE