Provider Demographics
NPI:1568725380
Name:BLACK, MYRIA GUNN (NP-C)
Entity Type:Individual
Prefix:MS
First Name:MYRIA
Middle Name:GUNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MEADE PKWY
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4259
Mailing Address - Country:US
Mailing Address - Phone:757-925-0759
Mailing Address - Fax:
Practice Address - Street 1:2000 MEADE PKWY
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4259
Practice Address - Country:US
Practice Address - Phone:757-925-0759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-18
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169925363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily