Provider Demographics
NPI:1225195670
Name:BLACK, LEAH I (CNM)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:I
Last Name:BLACK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0264
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:916 PACIFIC AVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4147
Practice Address - Country:US
Practice Address - Phone:425-303-6500
Practice Address - Fax:425-303-6550
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2009-01-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WARN00120454367A00000X
WAAP30006320367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9641473Medicaid
WAG8872683Medicare PIN
WA9641473Medicaid