Provider Demographics
NPI:1639477227
Name:BLACK, ASHLEY S (APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:S
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN-BC
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 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-6927
Mailing Address - Fax:864-512-6687
Practice Address - Street 1:100 HEALTHY WAY
Practice Address - Street 2:SUITE 1250
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-7915
Practice Address - Country:US
Practice Address - Phone:864-512-6927
Practice Address - Fax:864-512-6687
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4138363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP2003Medicaid