Provider Demographics
NPI:1346495793
Name:BLACK, HEATHER LEEANNE (RN)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:LEEANNE
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 1:15 LAZY TRL
Mailing Address - Street 2:
Mailing Address - City:PENFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:14526-1703
Mailing Address - Country:US
Mailing Address - Phone:585-598-3003
Mailing Address - Fax:
Practice Address - Street 1:15 LAZY TRL
Practice Address - Street 2:
Practice Address - City:PENFIELD
Practice Address - State:NY
Practice Address - Zip Code:14526-1703
Practice Address - Country:US
Practice Address - Phone:585-259-6840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-27
Last Update Date:2019-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY599392-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse