Provider Demographics
NPI:1194512798
Name:BLACK, CARLY JO
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:JO
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2006 AVENUE F
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBLUFF
Mailing Address - State:NE
Mailing Address - Zip Code:69361-4012
Mailing Address - Country:US
Mailing Address - Phone:308-641-3075
Mailing Address - Fax:
Practice Address - Street 1:2006 AVENUE F
Practice Address - Street 2:
Practice Address - City:SCOTTSBLUFF
Practice Address - State:NE
Practice Address - Zip Code:69361-4012
Practice Address - Country:US
Practice Address - Phone:308-641-3075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide