Provider Demographics
NPI:1477969814
Name:BLACK, MARI L (NP)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:L
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 1:272 HOSPITAL RD STE 6
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-9031
Mailing Address - Country:US
Mailing Address - Phone:740-779-4275
Mailing Address - Fax:740-779-4257
Practice Address - Street 1:4439 STATE ROUTE 159 STE G10
Practice Address - Street 2:
Practice Address - City:CHILLICOTHE
Practice Address - State:OH
Practice Address - Zip Code:45601-7708
Practice Address - Country:US
Practice Address - Phone:740-779-4300
Practice Address - Fax:740-779-4391
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2019-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH16040363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0108051Medicaid
WV3810027702Medicaid
OH0108051Medicaid