Provider Demographics
NPI:1447507462
Name:BLACK, ANGELA M (CNP)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:M
Last Name:BLACK
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6009 SW TAYLORS FERRY RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-5627
Mailing Address - Country:US
Mailing Address - Phone:740-398-6674
Mailing Address - Fax:
Practice Address - Street 1:901 RAINIER AVE S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-2839
Practice Address - Country:US
Practice Address - Phone:206-470-3880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-09
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.13918-NP363L00000X
OR201506660NP-PP363L00000X
WAAP60909585363L00000X
OH335437363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500691918Medicaid
OR161133OtherNORTH BEND MEDICAL CENTER GROUP MEDICAID
OR500691918Medicaid
OR1407812365OtherNORTH BEND MEDICAL CENTER GROUP NPI
OR93-0635514OtherNORTH BEND MEDICAL CENTER GROUP TAX ID
ORR0000WFBTVOtherNORTH BEND MEDICAL CENTER GROUP MEDICARE