Provider Demographics
NPI:1104337021
Name:BLACK, KAYLAH MCKINLEY (FNP-C)
Entity type:Individual
Prefix:
First Name:KAYLAH
Middle Name:MCKINLEY
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:KAYLAH
Other - Middle Name:RAE
Other - Last Name:MCKINLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:PO BOX 18563
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27619-8563
Mailing Address - Country:US
Mailing Address - Phone:919-858-0892
Mailing Address - Fax:919-342-3472
Practice Address - Street 1:530 NEW WAVERLY PL STE 301
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518
Practice Address - Country:US
Practice Address - Phone:919-747-0892
Practice Address - Fax:919-342-3472
Is Sole Proprietor?:No
Enumeration Date:2017-10-18
Last Update Date:2018-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21377363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner