Provider Demographics
NPI:1982056347
Name:BLACK, MEGAN LYNNE (APRN, AGNP-C)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LYNNE
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN, AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 PLEASANT ST
Mailing Address - Street 2:APT 2
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-3967
Mailing Address - Country:US
Mailing Address - Phone:978-257-3803
Mailing Address - Fax:
Practice Address - Street 1:43 BAXTER BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-1823
Practice Address - Country:US
Practice Address - Phone:207-771-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP161083363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care