Basic Information
| Provider Information | |||||||||
| NPI: | 1821195447 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | JUNE | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CLINIC DR | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424311661 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1756 E CENTER ST | ||||||||
| Address2: | |||||||||
| City: | MADISONVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424312253 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708213300 | ||||||||
| FaxNumber: | 2708212100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3002209 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 2209P | 01 | KY | LICENSE | OTHER | 000000044303 | 01 | BCBS PROVIDER NUMBER | OTHER | 78001153 | 05 | KY | MEDICAID | P00943823 | 01 | KY | RAILROAD MEDICARE- WALMART MADISONVILLE | OTHER |