Provider Demographics
NPI:1588829386
Name:BLACK, AMY JACQUELINE (NP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JACQUELINE
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-316-7760
Mailing Address - Fax:704-316-7761
Practice Address - Street 1:16525 HOLLY CREST LN STE 210
Practice Address - Street 2:
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078-4909
Practice Address - Country:US
Practice Address - Phone:704-316-7760
Practice Address - Fax:704-316-7761
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010060363L00000X
FL9304751363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner