Provider Demographics
NPI:1225195670
Name:BLACK, LEAH I (RN)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:I
Last Name:BLACK
Suffix:
Gender:F
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:PO BOX 5299
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98415-0299
Mailing Address - Country:US
Mailing Address - Phone:253-301-6490
Mailing Address - Fax:253-301-6531
Practice Address - Street 1:1313 BROADWAY STE 200
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3400
Practice Address - Country:US
Practice Address - Phone:253-301-6490
Practice Address - Fax:253-301-6531
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2024-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00120454163WH1000X
WAAP30006320367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH1000XNursing Service ProvidersRegistered NurseHospice
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9641473Medicaid
WAG8872683Medicare PIN
WA9641473Medicaid