Provider Demographics
NPI:1104692763
Name:BLACK, KATIE (CPM, LM, RN)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:CPM, LM, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:948 REFUGE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:STEPHENS CITY
Mailing Address - State:VA
Mailing Address - Zip Code:22655-5621
Mailing Address - Country:US
Mailing Address - Phone:703-217-3941
Mailing Address - Fax:
Practice Address - Street 1:100 FOUNDERS WAY STE 5
Practice Address - Street 2:
Practice Address - City:STRASBURG
Practice Address - State:VA
Practice Address - Zip Code:22657-3791
Practice Address - Country:US
Practice Address - Phone:540-227-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-27
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0129000195176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife