Provider Demographics
NPI:1891243622
Name:BLACK, PAMELA J
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:J
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:903 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:KS
Mailing Address - Zip Code:67467-1705
Mailing Address - Country:US
Mailing Address - Phone:785-224-5810
Mailing Address - Fax:
Practice Address - Street 1:903 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:KS
Practice Address - Zip Code:67467-1705
Practice Address - Country:US
Practice Address - Phone:785-224-5810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-00129171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor