Provider Demographics
NPI:1962991125
Name:BLACK, ALVA MARIE
Entity type:Individual
Prefix:
First Name:ALVA
Middle Name:MARIE
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 1:386 MOORES CREEK RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:24450-7009
Mailing Address - Country:US
Mailing Address - Phone:540-463-4447
Mailing Address - Fax:
Practice Address - Street 1:241 GREENHOUSE RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:VA
Practice Address - Zip Code:24450-3717
Practice Address - Country:US
Practice Address - Phone:540-463-3141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001208688163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse