Provider Demographics
NPI:1992100366
Name:BLACK, CAROL LYNN
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNN
Last Name:BLACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROL
Other - Middle Name:LYNN
Other - Last Name:CHAMBERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:950 THISTLE MEADE CIR
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-6799
Mailing Address - Country:US
Mailing Address - Phone:817-995-8625
Mailing Address - Fax:
Practice Address - Street 1:950 THISTLE MEADE CIR
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-6799
Practice Address - Country:US
Practice Address - Phone:817-995-8625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX528145163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant