Provider Demographics
NPI:1306051867
Name:BLACK, JANET LYNN (ARNP, RN)
Entity type:Individual
Prefix:MS
First Name:JANET
Middle Name:LYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:ARNP, RN
Other - Prefix:MS
Other - First Name:JANET
Other - Middle Name:BLACK
Other - Last Name:COSTANTINOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP, RN
Mailing Address - Street 1:5040 STATE HIGHWAY 507 SE
Mailing Address - Street 2:
Mailing Address - City:TENINO
Mailing Address - State:WA
Mailing Address - Zip Code:98589-9661
Mailing Address - Country:US
Mailing Address - Phone:360-264-5665
Mailing Address - Fax:360-264-5666
Practice Address - Street 1:273 SUSSEX AVE E
Practice Address - Street 2:
Practice Address - City:TENINO
Practice Address - State:WA
Practice Address - Zip Code:98589-9359
Practice Address - Country:US
Practice Address - Phone:360-264-5665
Practice Address - Fax:360-264-5666
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30004239363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily