Provider Demographics
NPI:1467983346
Name:BLACK, LANA (NP)
Entity Type:Individual
Prefix:
First Name:LANA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1100 E MICHIGAN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1800
Mailing Address - Country:US
Mailing Address - Phone:517-205-3924
Mailing Address - Fax:517-205-3343
Practice Address - Street 1:130 N SHERMAN ST
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251-9409
Practice Address - Country:US
Practice Address - Phone:517-205-2500
Practice Address - Fax:517-205-2516
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2021-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704171858363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily