Provider Demographics
NPI:1780834549
Name:BLACK, SUSAN
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:227 HOSPITAL DR STE 1
Mailing Address - Street 2:SUITE 1
Mailing Address - City:EVERETT
Mailing Address - State:PA
Mailing Address - Zip Code:15537-7019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 HOSPITAL DR STE 1
Practice Address - Street 2:SUITE 1
Practice Address - City:EVERETT
Practice Address - State:PA
Practice Address - Zip Code:15537-7019
Practice Address - Country:US
Practice Address - Phone:814-623-9095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-29
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009927363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily