Provider Demographics
NPI:1083421812
Name:BLACK, LINDSEY MAE (PNP)
Entity type:Individual
Prefix:
First Name:LINDSEY
Middle Name:MAE
Last Name:BLACK
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:983 S GETTYSBURG LOOP
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-4238
Mailing Address - Country:US
Mailing Address - Phone:816-695-1185
Mailing Address - Fax:
Practice Address - Street 1:1335 E REPUBLIC RD STE D
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-7220
Practice Address - Country:US
Practice Address - Phone:417-363-3900
Practice Address - Fax:417-313-9998
Is Sole Proprietor?:No
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2024048637363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics