Provider Demographics
NPI:1376203802
Name:BLACK, NICOLE (CRNA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-3075
Mailing Address - Country:US
Mailing Address - Phone:517-375-1808
Mailing Address - Fax:
Practice Address - Street 1:5301 MCAULEY DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1051
Practice Address - Country:US
Practice Address - Phone:734-712-3456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-24
Last Update Date:2021-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI139623367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered