Provider Demographics
NPI:1962464057
Name:BLACK, RENAE LAREE (CNM)
Entity type:Individual
Prefix:MS
First Name:RENAE
Middle Name:LAREE
Last Name:BLACK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 TRAVELODGE DR
Mailing Address - Street 2:KAISER PERMANENTE
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-4126
Mailing Address - Country:US
Mailing Address - Phone:619-441-3021
Mailing Address - Fax:
Practice Address - Street 1:250 TRAVELODGE DR
Practice Address - Street 2:KAISER PERMANENTE
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-4126
Practice Address - Country:US
Practice Address - Phone:619-441-3021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA446374176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife