Provider Demographics
NPI:1134765886
Name:BLACK, EVA MARIE (APRN-C)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:MARIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91 PHOENIX AVE
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:AL
Mailing Address - Zip Code:35447-2351
Mailing Address - Country:US
Mailing Address - Phone:662-549-4050
Mailing Address - Fax:
Practice Address - Street 1:415 DERBY DR
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:AL
Practice Address - Zip Code:36925-2117
Practice Address - Country:US
Practice Address - Phone:205-392-9656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901756363LF0000X
TN27493363LF0000X
AL1-168015363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-168015OtherALABAMA LICENSE
TN27493OtherTN LICENSE