Provider Demographics
NPI:1821195447
Name:BLACK, CARRIE JUNE (ARNP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:JUNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1756 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-2253
Practice Address - Country:US
Practice Address - Phone:270-821-3300
Practice Address - Fax:270-821-2100
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002209363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY2209POtherLICENSE
000000044303OtherBCBS PROVIDER NUMBER
KY78001153Medicaid
KYP00943823OtherRAILROAD MEDICARE- WALMART MADISONVILLE
KY500009519Medicare PIN
000000044303OtherBCBS PROVIDER NUMBER
KYP00943823OtherRAILROAD MEDICARE- WALMART MADISONVILLE
KYP400037641Medicare PIN
KY2209POtherLICENSE
0374511Medicare PIN