Provider Demographics
NPI:1861089443
Name:BLACK, DESTANEE
Entity type:Individual
Prefix:
First Name:DESTANEE
Middle Name:
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:PO BOX 415
Mailing Address - Street 2:
Mailing Address - City:FORT TOTTEN
Mailing Address - State:ND
Mailing Address - Zip Code:58335-0415
Mailing Address - Country:US
Mailing Address - Phone:701-766-4382
Mailing Address - Fax:
Practice Address - Street 1:63 HOUSING CIRCLE DR
Practice Address - Street 2:
Practice Address - City:FORT TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335-3525
Practice Address - Country:US
Practice Address - Phone:701-766-4382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant