Provider Demographics
NPI:1144351800
Name:BLACK, SUSAN IRENE (RN, NP, CNM)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:IRENE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN, NP, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 E GLENN ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-1606
Mailing Address - Country:US
Mailing Address - Phone:520-795-3480
Mailing Address - Fax:
Practice Address - Street 1:1224 E LOWELL ST
Practice Address - Street 2:BLDG 95
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85721-0095
Practice Address - Country:US
Practice Address - Phone:520-621-4801
Practice Address - Fax:520-626-5736
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN039229363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology