Provider Demographics
NPI:1790982080
Name:BLACK, THERESA ANN (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:ANN
Other - Last Name:BLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:812 GORMAN AVENUE
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241
Mailing Address - Country:US
Mailing Address - Phone:304-637-3456
Mailing Address - Fax:304-637-3441
Practice Address - Street 1:11 N LOCUST ST
Practice Address - Street 2:
Practice Address - City:BUCKHANNON
Practice Address - State:WV
Practice Address - Zip Code:26201-4707
Practice Address - Country:US
Practice Address - Phone:304-472-1600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV49062363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009382Medicaid
WV3810009382Medicaid