Provider Demographics
NPI:1649943937
Name:BLACK, ALEXIS (CNP)
Entity type:Individual
Prefix:MS
First Name:ALEXIS
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 E PIN OAK DR
Mailing Address - Street 2:
Mailing Address - City:SAINT ROSE
Mailing Address - State:LA
Mailing Address - Zip Code:70087-3239
Mailing Address - Country:US
Mailing Address - Phone:504-554-3034
Mailing Address - Fax:
Practice Address - Street 1:1057 PAUL MAILLARD RD STE D-1900
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4349
Practice Address - Country:US
Practice Address - Phone:985-785-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-01
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA221427363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily