Provider Demographics
NPI:1457169104
Name:BLACK, DEIDRA
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 16TH AVE N APT A
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37208-2001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1705 16TH AVE N APT A
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37208-2001
Practice Address - Country:US
Practice Address - Phone:229-895-3546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker