Provider Demographics
NPI:1902587546
Name:BLACK, LAUREN ELIZABETH (MSN, RN, AGCNS-BC)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:BLACK
Suffix:
Gender:F
Credentials:MSN, RN, AGCNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3738 W JEFFREY RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-4116
Mailing Address - Country:US
Mailing Address - Phone:812-360-2355
Mailing Address - Fax:
Practice Address - Street 1:2651 E DISCOVERY PKWY RM A1141B
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47408-9059
Practice Address - Country:US
Practice Address - Phone:812-918-3752
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28222833A163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse