Provider Demographics
NPI:1730972456
Name:BLACK, MERILYN ALICE
Entity type:Individual
Prefix:
First Name:MERILYN
Middle Name:ALICE
Last Name:BLACK
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 CHEROKEE PASS
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:WV
Mailing Address - Zip Code:26704-7625
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:316 CHEROKEE PASS
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:WV
Practice Address - Zip Code:26704-7625
Practice Address - Country:US
Practice Address - Phone:443-618-8040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-26
Last Update Date:2025-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide