Provider Demographics
NPI:1679051668
Name:BLACK, MARY ELIZABETH (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 SCHOOL DRIVE
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:AR
Mailing Address - Zip Code:72153
Mailing Address - Country:US
Mailing Address - Phone:501-723-4400
Mailing Address - Fax:501-745-3006
Practice Address - Street 1:199 SCHOOL DRIVE
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:AR
Practice Address - Zip Code:72153
Practice Address - Country:US
Practice Address - Phone:501-723-4400
Practice Address - Fax:501-723-4444
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily