Provider Demographics
NPI:1982092847
Name:BLACK, NATASHA
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
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 1:73 MESSENGER LN
Mailing Address - Street 2:
Mailing Address - City:KINGSTREE
Mailing Address - State:SC
Mailing Address - Zip Code:29556-5576
Mailing Address - Country:US
Mailing Address - Phone:843-592-9145
Mailing Address - Fax:
Practice Address - Street 1:407 BOONE HILL RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-3501
Practice Address - Country:US
Practice Address - Phone:843-592-9145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-30
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCP34076164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse