Provider Demographics
NPI:1609879162
Name:PHILLIPS-BLACK, LEAH D (ARNP)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:D
Last Name:PHILLIPS-BLACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:800 ZORN AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40206-1433
Mailing Address - Country:US
Mailing Address - Phone:502-287-4000
Mailing Address - Fax:502-287-6906
Practice Address - Street 1:800 ZORN AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40206-1433
Practice Address - Country:US
Practice Address - Phone:502-287-4000
Practice Address - Fax:502-287-6906
Is Sole Proprietor?:No
Enumeration Date:2005-05-27
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4140P363L00000X
IN71001612A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200474340AMedicaid
IN200474340AMedicaid
INP99778Medicare UPIN