Provider Demographics
NPI:1013427129
Name:BLACK, CAROL LYNN (APRN-CNP)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:610 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3245
Mailing Address - Country:US
Mailing Address - Phone:580-371-2343
Mailing Address - Fax:580-371-3614
Practice Address - Street 1:107 E POST AVE
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-3004
Practice Address - Country:US
Practice Address - Phone:580-927-2828
Practice Address - Fax:580-927-9876
Is Sole Proprietor?:No
Enumeration Date:2017-10-03
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK67047363LF0000X
OKR0067047363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F09170047OtherAANP CERTIFICATION NUMBER