Provider Demographics
NPI:1679823306
Name:BLACK, ASHLEY NICOLE (APRN)
Entity Type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 WAL MART WAY
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41056-7518
Mailing Address - Country:US
Mailing Address - Phone:606-759-0021
Mailing Address - Fax:606-759-0086
Practice Address - Street 1:191 WAL MART WAY
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-7518
Practice Address - Country:US
Practice Address - Phone:606-759-0021
Practice Address - Fax:606-759-0086
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007563363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075274Medicaid
KY71002222550Medicaid
KYK072140Medicare PIN