Provider Demographics
NPI:1962009324
Name:BLACK, ELLIE CATHARINE (FNP-C)
Entity Type:Individual
Prefix:
First Name:ELLIE
Middle Name:CATHARINE
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2345 E PRATER WAY STE 207
Mailing Address - Street 2:
Mailing Address - City:SPARKS
Mailing Address - State:NV
Mailing Address - Zip Code:89434-9634
Mailing Address - Country:US
Mailing Address - Phone:775-352-5335
Mailing Address - Fax:775-352-5334
Practice Address - Street 1:5265 VISTA BLVD BLDG B
Practice Address - Street 2:
Practice Address - City:SPARKS
Practice Address - State:NV
Practice Address - Zip Code:89436-0836
Practice Address - Country:US
Practice Address - Phone:775-352-5335
Practice Address - Fax:775-352-5334
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014901363LP2300X
NV832783363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care