Basic Information
| Provider Information | |||||||||
| NPI: | 1003151028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACK | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 EAGLE SPRING DR | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702133366 | ||||||||
| FaxNumber: | 4049626943 | ||||||||
| Practice Location | |||||||||
| Address1: | 125 EAGLE SPRING DR | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302816328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7702133366 | ||||||||
| FaxNumber: | 4049626943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2012 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN146749 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.