Provider Demographics
NPI:1366623191
Name:BLACK, CATHERINE R
Entity Type:Individual
Prefix:
First Name:CATHERINE
Middle Name:R
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 1:280 RIVER PARK DR
Mailing Address - Street 2:#200
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-5764
Mailing Address - Country:US
Mailing Address - Phone:801-223-4860
Mailing Address - Fax:801-371-8993
Practice Address - Street 1:280 RIVER PARK DR
Practice Address - Street 2:SUITE 200
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-5764
Practice Address - Country:US
Practice Address - Phone:801-223-4860
Practice Address - Fax:801-371-8993
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT198805-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily