Provider Demographics
NPI:1225131691
Name:BLACK, REBECCA E (RN)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:E
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 471
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29709
Mailing Address - Country:US
Mailing Address - Phone:843-623-2229
Mailing Address - Fax:843-623-2553
Practice Address - Street 1:207 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:SC
Practice Address - Zip Code:29709
Practice Address - Country:US
Practice Address - Phone:843-623-2229
Practice Address - Fax:843-623-2553
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC56924163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC405127Medicaid
SC405127Medicaid