Provider Demographics
NPI:1679551329
Name:BLACK, LAURIE JO (RN CNP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:JO
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN CNP
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:JO
Other - Last Name:PEREIRA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:CENTRA CARE CLINIC
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-251-2700
Mailing Address - Fax:
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:CENTRA CARE CLINIC
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-251-2700
Practice Address - Fax:727-587-7739
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2638602363LP0200X
MNR217274-5363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0307418800Medicaid
FLGC696ZMedicare PIN