Provider Demographics
NPI:1457534786
Name:BLACK, SHARON (RD)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 S BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-2212
Mailing Address - Country:US
Mailing Address - Phone:765-655-2641
Mailing Address - Fax:
Practice Address - Street 1:1542 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2212
Practice Address - Country:US
Practice Address - Phone:765-655-2641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-10
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
410941133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered