Provider Demographics
NPI:1285368423
Name:BLACK, CHRISTAN SHADEENE (AGNP-BC)
Entity type:Individual
Prefix:MS
First Name:CHRISTAN
Middle Name:SHADEENE
Last Name:BLACK
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2001 TODAYS WOMAN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-5069
Practice Address - Country:US
Practice Address - Phone:336-722-1818
Practice Address - Fax:336-722-1826
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2021103998363LG0600X
NC5018146363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology