Provider Demographics
NPI:1518037993
Name:BLACK, MERNA G (LM, CPM)
Entity Type:Individual
Prefix:MS
First Name:MERNA
Middle Name:G
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 1:5402 SIOUX
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:NM
Mailing Address - Zip Code:88220-9543
Mailing Address - Country:US
Mailing Address - Phone:505-887-3727
Mailing Address - Fax:
Practice Address - Street 1:5402 SIOUX RD.
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:NM
Practice Address - Zip Code:88220-9543
Practice Address - Country:US
Practice Address - Phone:505-887-3727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM96366R176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife