Provider Demographics
NPI:1679051668
Name:BLACK, MARY ELIZABETH (NP-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 VOLUNTEER PKWY
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:AR
Mailing Address - Zip Code:72031-8001
Mailing Address - Country:US
Mailing Address - Phone:501-745-3388
Mailing Address - Fax:501-745-3006
Practice Address - Street 1:175 VOLUNTEER PKWY
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:AR
Practice Address - Zip Code:72031-8001
Practice Address - Country:US
Practice Address - Phone:501-745-3388
Practice Address - Fax:501-745-3006
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily