Provider Demographics
NPI:1487325007
Name:BLACK, ALLISON (RN)
Entity type:Individual
Prefix:
First Name:ALLISON
Middle Name:
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 1:12351 S GATEWAY PARK PL STE D-700
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-9581
Mailing Address - Country:US
Mailing Address - Phone:801-970-3676
Mailing Address - Fax:
Practice Address - Street 1:12351 S GATEWAY PARK PL STE D-700
Practice Address - Street 2:
Practice Address - City:DRAPER
Practice Address - State:UT
Practice Address - Zip Code:84020-9581
Practice Address - Country:US
Practice Address - Phone:801-970-3676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5921723-3102163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse