Provider Demographics
NPI:1124827183
Name:BLACK, JOEY ROBERT (RN)
Entity type:Individual
Prefix:
First Name:JOEY
Middle Name:ROBERT
Last Name:BLACK
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 COUNTY ROUTE 17
Mailing Address - Street 2:
Mailing Address - City:RUSSELL
Mailing Address - State:NY
Mailing Address - Zip Code:13684-4401
Mailing Address - Country:US
Mailing Address - Phone:315-347-2566
Mailing Address - Fax:
Practice Address - Street 1:1 CHIMNEY POINT DR
Practice Address - Street 2:
Practice Address - City:OGDENSBURG
Practice Address - State:NY
Practice Address - Zip Code:13669-2291
Practice Address - Country:US
Practice Address - Phone:315-541-2500
Practice Address - Fax:315-541-2089
Is Sole Proprietor?:No
Enumeration Date:2025-03-12
Last Update Date:2025-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY573182163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse