Provider Demographics
NPI:1598123598
Name:BLACK, DANDREA (RN)
Entity Type:Individual
Prefix:
First Name:DANDREA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 ADRIANA LN
Mailing Address - Street 2:
Mailing Address - City:HUTTO
Mailing Address - State:TX
Mailing Address - Zip Code:78634-5665
Mailing Address - Country:US
Mailing Address - Phone:512-913-9809
Mailing Address - Fax:
Practice Address - Street 1:5225 N. LAMAR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78751-5665
Practice Address - Country:US
Practice Address - Phone:512-483-5800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-04
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX763654163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse