Provider Demographics
NPI:1992396022
Name:BLACK, TIMONTHY DONELL
Entity Type:Individual
Prefix:
First Name:TIMONTHY
Middle Name:DONELL
Last Name:BLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1132 CARTER MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:STUART
Mailing Address - State:VA
Mailing Address - Zip Code:24171-3769
Mailing Address - Country:US
Mailing Address - Phone:336-345-6731
Mailing Address - Fax:
Practice Address - Street 1:113 SCENIC OUTLET LN STE 2
Practice Address - Street 2:
Practice Address - City:MOUNT AIRY
Practice Address - State:NC
Practice Address - Zip Code:27030-9978
Practice Address - Country:US
Practice Address - Phone:336-352-4900
Practice Address - Fax:336-352-4901
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC5014067363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program