Provider Demographics
NPI:1780944520
Name:BLACK, LISA ANNE (ARNP)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561600
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1600
Mailing Address - Country:US
Mailing Address - Phone:321-259-0635
Mailing Address - Fax:321-434-4642
Practice Address - Street 1:220 S COURTENAY PKWY
Practice Address - Street 2:SUITE B
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-4893
Practice Address - Country:US
Practice Address - Phone:321-868-5815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-28
Last Update Date:2012-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2159422363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily