Provider Demographics
NPI:1922754134
Name:BLACK, JULI SUZANNE
Entity Type:Individual
Prefix:
First Name:JULI
Middle Name:SUZANNE
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 1:32518 RIVER VISTA LN
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-9564
Mailing Address - Country:US
Mailing Address - Phone:408-484-4451
Mailing Address - Fax:
Practice Address - Street 1:32518 RIVER VISTA LN
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-9564
Practice Address - Country:US
Practice Address - Phone:309-229-6956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9026363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health