Provider Demographics
NPI:1912646373
Name:BLACK, MYESA HARRIS
Entity Type:Individual
Prefix:
First Name:MYESA
Middle Name:HARRIS
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 1:12669 TOBYTOWN DR
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854-6019
Mailing Address - Country:US
Mailing Address - Phone:240-422-3698
Mailing Address - Fax:
Practice Address - Street 1:4200 S CAPITOL ST SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-1342
Practice Address - Country:US
Practice Address - Phone:202-766-6418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA001909073747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant