Provider Demographics
NPI:1851514764
Name:BLACK, PATRICIA ANN (RN)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4402 VAN DYKE RD
Mailing Address - Street 2:
Mailing Address - City:BROWN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48416-9631
Mailing Address - Country:US
Mailing Address - Phone:810-537-2139
Mailing Address - Fax:
Practice Address - Street 1:217 E SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1383
Practice Address - Country:US
Practice Address - Phone:810-648-4327
Practice Address - Fax:810-648-4338
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704069005163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent