Basic Information
| Provider Information | |||||||||
| NPI: | 1225195670 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | I. | ||||||||
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| Credential: | C.N.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 909 N BROADWAY | ||||||||
| Address2: | PBO | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253170264 | ||||||||
| FaxNumber: | 4253170291 | ||||||||
| Practice Location | |||||||||
| Address1: | 916 PACIFIC AVE | ||||||||
| Address2: | 7TH FLOOR | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982014147 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253036500 | ||||||||
| FaxNumber: | 4253036550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2007 | ||||||||
| LastUpdateDate: | 01/30/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | RN00120454 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 367A00000X | AP30006320 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 9641473 | 05 | WA | MEDICAID |