Provider Demographics
NPI:1356813984
Name:BLACK, MARY ANN (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
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 1:1334 DALLAS AVE
Mailing Address - Street 2:
Mailing Address - City:WINTER PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32789-3641
Mailing Address - Country:US
Mailing Address - Phone:407-647-5521
Mailing Address - Fax:
Practice Address - Street 1:1334 DALLAS AVE
Practice Address - Street 2:
Practice Address - City:WINTER PARK
Practice Address - State:FL
Practice Address - Zip Code:32789-3641
Practice Address - Country:US
Practice Address - Phone:407-647-5521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-20
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN743762163WC1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff DevelopmentGroup - Single Specialty