Provider Demographics
NPI:1487164901
Name:BLACK, CHARITI (NP-C)
Entity type:Individual
Prefix:
First Name:CHARITI
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7002 TREELINE DR
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:TN
Mailing Address - Zip Code:37341-9564
Mailing Address - Country:US
Mailing Address - Phone:423-313-3688
Mailing Address - Fax:
Practice Address - Street 1:2158 NORTHGATE PARK LN STE 300
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37415-6959
Practice Address - Country:US
Practice Address - Phone:423-771-9680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-11
Last Update Date:2017-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN22769363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily