Healthcare Provider Details

I. General information

NPI: 1659407617
Provider Name (Legal Business Name): CHRISTINE MARIE SLACK LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 E BROADWAY AVE
APACHE JUNCTION AZ
85219-9301
US

IV. Provider business mailing address

10470 E DUTCHMANS TRL
GOLD CANYON AZ
85218-4916
US

V. Phone/Fax

Practice location:
  • Phone: 480-982-1110
  • Fax: 480-288-0532
Mailing address:
  • Phone: 480-983-2311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP040169
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: