Basic Information
| Provider Information | |||||||||
| NPI: | 1477969814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | MARI | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 272 HOSPITAL RD STE 6 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456019031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794275 | ||||||||
| FaxNumber: | 7407794257 | ||||||||
| Practice Location | |||||||||
| Address1: | 4439 STATE ROUTE 159 STE G10 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456017708 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407794300 | ||||||||
| FaxNumber: | 7407794391 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2014 | ||||||||
| LastUpdateDate: | 03/22/2019 | ||||||||
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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 | 363LF0000X | 16040 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 0108051 | 05 | OH | MEDICAID | 3810027702 | 05 | WV | MEDICAID |