Provider Demographics
NPI:1104557412
Name:BLACK, LORRAINE (PMHNP)
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 104
Mailing Address - Street 2:
Mailing Address - City:NICEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32588-0104
Mailing Address - Country:US
Mailing Address - Phone:850-280-4834
Mailing Address - Fax:850-661-3888
Practice Address - Street 1:7901 4TH ST N STE 300
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33702-4399
Practice Address - Country:US
Practice Address - Phone:727-594-8875
Practice Address - Fax:850-661-3888
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2025-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020305363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health