Provider Demographics
NPI:1174042634
Name:BLACK, KIMBERLY SUE (RN)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUE
Last Name:BLACK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7150 CLEARVISTA DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46256-1695
Mailing Address - Country:US
Mailing Address - Phone:317-621-5017
Mailing Address - Fax:
Practice Address - Street 1:7150 CLEARVISTA DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46256-1695
Practice Address - Country:US
Practice Address - Phone:317-509-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28097369A163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice