Provider Demographics
NPI:1295122059
Name:BLACK, MICHELLE
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:406 N SPRING ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-2134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:406 N SPRING ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2134
Practice Address - Country:US
Practice Address - Phone:931-507-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-20
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN176618163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse