Provider Demographics
NPI:1851451579
Name:BLACK, LAURA DIANE (FNP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:DIANE
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 PANORAMA DRIVE
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-6800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:HUMBOLDT STATE UNIVERSITY
Practice Address - Street 2:
Practice Address - City:ARCATA
Practice Address - State:CA
Practice Address - Zip Code:95521-8299
Practice Address - Country:US
Practice Address - Phone:707-826-3146
Practice Address - Fax:707-826-5052
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2016-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7155363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner