Provider Demographics
NPI:1497086219
Name:BLACK, LISA LYNN (LM,CPM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:LM,CPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3917 HICKORY BEND TRL
Mailing Address - Street 2:
Mailing Address - City:MCKINNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75071-2776
Mailing Address - Country:US
Mailing Address - Phone:214-394-5687
Mailing Address - Fax:972-562-5174
Practice Address - Street 1:3917 HICKORY BEND TRL
Practice Address - Street 2:
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071-2776
Practice Address - Country:US
Practice Address - Phone:214-394-5687
Practice Address - Fax:972-562-5174
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-18
Last Update Date:2010-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX02008176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX02008OtherTEXAS MIDWIFERY LICENSE