Provider Demographics
NPI:1538927249
Name:BLACK, MADISON (APRN)
Entity type:Individual
Prefix:MRS
First Name:MADISON
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3515 W 73RD TER
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE VILLAGE
Mailing Address - State:KS
Mailing Address - Zip Code:66208-2908
Mailing Address - Country:US
Mailing Address - Phone:816-898-0782
Mailing Address - Fax:
Practice Address - Street 1:7501 METCALF AVE
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66204-2927
Practice Address - Country:US
Practice Address - Phone:913-642-6330
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS13-150204-042163W00000X
KS53-82981-042363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse