Provider Demographics
NPI:1851717573
Name:BLACK, HEATHER WYNNE (NP)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:WYNNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:FAITH
Other - Last Name:WYNNE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 12248
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28561-2248
Mailing Address - Country:US
Mailing Address - Phone:252-636-6222
Mailing Address - Fax:252-636-5385
Practice Address - Street 1:670 CARDINAL RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5201
Practice Address - Country:US
Practice Address - Phone:252-636-6222
Practice Address - Fax:252-636-5385
Is Sole Proprietor?:No
Enumeration Date:2014-03-06
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5006809363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily