Provider Demographics
NPI:1376109736
Name:BLACK, LAURIE ANN (RN, FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 775383
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-5383
Mailing Address - Country:US
Mailing Address - Phone:812-376-5315
Mailing Address - Fax:812-375-3477
Practice Address - Street 1:1655 N GLADSTONE AVE STE A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:IN
Practice Address - Zip Code:47201-5380
Practice Address - Country:US
Practice Address - Phone:812-376-3100
Practice Address - Fax:812-378-6191
Is Sole Proprietor?:No
Enumeration Date:2019-05-11
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28200199A363LF0000X
IN71009191A363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily