Provider Demographics
NPI:1144632217
Name:BLACK, SOUSAN YAZDI (ARNP)
Entity type:Individual
Prefix:
First Name:SOUSAN
Middle Name:YAZDI
Last Name:BLACK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SOUSAN
Other - Middle Name:AKHAVAN
Other - Last Name:YAZDI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:8931 COLONIAL CENTER DR
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33905-7809
Practice Address - Country:US
Practice Address - Phone:239-938-0800
Practice Address - Fax:239-938-0890
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2014-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9293083363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health