Provider Demographics
NPI:1740296516
Name:BLACK, FREDA ANN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:FREDA
Middle Name:ANN
Last Name:BLACK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W JEFFERSON BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46601-1923
Mailing Address - Country:US
Mailing Address - Phone:574-546-1900
Mailing Address - Fax:574-546-1999
Practice Address - Street 1:112 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1923
Practice Address - Country:US
Practice Address - Phone:574-546-1900
Practice Address - Fax:574-546-1999
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.005685363LA2200X
IN71001497363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN28104924AOtherRN LICENSE NUMBER
IN71001497AOtherAPN LICENSE NUMBER
IL041.335636OtherRN LICENSE NUMBER
IL209.005685OtherAPN LICENSE NUMBER