Provider Demographics
NPI:1487499489
Name:BLACK, RONNA LEIGH
Entity type:Individual
Prefix:
First Name:RONNA
Middle Name:LEIGH
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5891 DAVIS CREEK RD TRLR 32
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-1154
Mailing Address - Country:US
Mailing Address - Phone:304-972-5667
Mailing Address - Fax:
Practice Address - Street 1:1 KINGS CT
Practice Address - Street 2:
Practice Address - City:ONA
Practice Address - State:WV
Practice Address - Zip Code:25545-9746
Practice Address - Country:US
Practice Address - Phone:304-972-5667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-01
Last Update Date:2024-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV26416164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse