Provider Demographics
NPI:1275662983
Name:BLACK, MARILYN SUE
Entity Type:Individual
Prefix:MS
First Name:MARILYN
Middle Name:SUE
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 1:1704 DOVER AVE
Mailing Address - Street 2:
Mailing Address - City:PIQUA
Mailing Address - State:OH
Mailing Address - Zip Code:45356-2724
Mailing Address - Country:US
Mailing Address - Phone:937-615-9496
Mailing Address - Fax:937-615-9496
Practice Address - Street 1:81A RHOADS CENTER DR
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458
Practice Address - Country:US
Practice Address - Phone:800-538-4218
Practice Address - Fax:937-435-0980
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400421721004STNA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2604962OtherCARESTAR