Basic Information
Provider Information
NPI: 1598123598
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: BLACK
FirstName: DANDREA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: RN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 203 ADRIANA LN
Address2:  
City: HUTTO
State: TX
PostalCode: 786345665
CountryCode: US
TelephoneNumber: 5129139809
FaxNumber:  
Practice Location
Address1: 5225 N. LAMAR
Address2:  
City: AUSTIN
State: TX
PostalCode: 787515665
CountryCode: US
TelephoneNumber: 5124835800
FaxNumber:  
Other Information
ProviderEnumerationDate: 02/04/2016
LastUpdateDate: 02/08/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
163W00000X763654TXY Nursing Service ProvidersRegistered Nurse 

No ID Information.


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