Provider Demographics
NPI:1538875935
Name:BLACK, RILEY MACKENZIE (DNP)
Entity type:Individual
Prefix:DR
First Name:RILEY
Middle Name:MACKENZIE
Last Name:BLACK
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:198 CHERRY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LIBBY
Mailing Address - State:MT
Mailing Address - Zip Code:59923-7848
Mailing Address - Country:US
Mailing Address - Phone:406-291-1994
Mailing Address - Fax:
Practice Address - Street 1:401 LOUISIANA AVE
Practice Address - Street 2:
Practice Address - City:LIBBY
Practice Address - State:MT
Practice Address - Zip Code:59923-2131
Practice Address - Country:US
Practice Address - Phone:406-283-7440
Practice Address - Fax:406-293-4780
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-30
Last Update Date:2024-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLIC103602163WP0808X
MTNUR-APRN-LIC-240991363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0801419904108OtherDRIVERS LICENSE