Provider Demographics
NPI:1316555089
Name:BLACK, SONJA RENA (RN)
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:RENA
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 1:213 WINESPRING PL
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-6213
Mailing Address - Country:US
Mailing Address - Phone:864-430-0996
Mailing Address - Fax:
Practice Address - Street 1:213 WINESPRING PL
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-6213
Practice Address - Country:US
Practice Address - Phone:864-430-0996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC232700163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No163W00000XNursing Service ProvidersRegistered Nurse