Provider Demographics
NPI:1134014939
Name:BLACK, BRIANNE ELLIS (FNP)
Entity type:Individual
Prefix:MRS
First Name:BRIANNE
Middle Name:ELLIS
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1648 CARTER ST
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:LA
Mailing Address - Zip Code:71373-3111
Mailing Address - Country:US
Mailing Address - Phone:318-607-5870
Mailing Address - Fax:318-607-5870
Practice Address - Street 1:1648 CARTER ST STE 2
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:LA
Practice Address - Zip Code:71373-3111
Practice Address - Country:US
Practice Address - Phone:318-414-2315
Practice Address - Fax:318-414-5250
Is Sole Proprietor?:No
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine