Provider Demographics
NPI:1871115832
Name:BLACK, SHEILA (FNP-C)
Entity type:Individual
Prefix:
First Name:SHEILA
Middle Name:
Last Name:BLACK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:916-636-4358
Practice Address - Street 1:1001 DIVISION ST
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1601
Practice Address - Country:US
Practice Address - Phone:928-445-5648
Practice Address - Fax:928-445-5079
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2025-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ240338363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ080244Medicaid
AZ240338OtherSTATE BOARD OF NURSING
AZ240338OtherSTATE BOARD OF NURSING