Provider Demographics
NPI:1871885327
Name:BLACK, TAWANNA LEVELLE (LPN)
Entity type:Individual
Prefix:MS
First Name:TAWANNA
Middle Name:LEVELLE
Last Name:BLACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 BROOKS AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-2317
Mailing Address - Country:US
Mailing Address - Phone:585-360-5992
Mailing Address - Fax:
Practice Address - Street 1:412 BROOKS AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-2317
Practice Address - Country:US
Practice Address - Phone:585-360-5992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-03
Last Update Date:2011-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY286202164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY286202OtherLPN