Provider Demographics
NPI:1821821281
Name:BLACK, ERICA
Entity type:Individual
Prefix:
First Name:ERICA
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 1:4937 W JAMESTOWN TRCE
Mailing Address - Street 2:
Mailing Address - City:NEW PALESTINE
Mailing Address - State:IN
Mailing Address - Zip Code:46163-8565
Mailing Address - Country:US
Mailing Address - Phone:317-403-5018
Mailing Address - Fax:
Practice Address - Street 1:4937 W JAMESTOWN TRCE
Practice Address - Street 2:
Practice Address - City:NEW PALESTINE
Practice Address - State:IN
Practice Address - Zip Code:46163-8565
Practice Address - Country:US
Practice Address - Phone:317-403-5018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN24-017477-13747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider