Provider Demographics
NPI:1639208523
Name:BLACK, DONNA JEAN (AP,MAC)
Entity Type:Individual
Prefix:MS
First Name:DONNA
Middle Name:JEAN
Last Name:BLACK
Suffix:
Gender:F
Credentials:AP,MAC
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 2792
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32602-2792
Mailing Address - Country:US
Mailing Address - Phone:352-337-2702
Mailing Address - Fax:352-378-5166
Practice Address - Street 1:1705 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32609-3531
Practice Address - Country:US
Practice Address - Phone:352-337-2702
Practice Address - Fax:352-378-5166
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP813171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC0400OtherBLUE CROSS BLUE SHEILD