Healthcare Provider Details

I. General information

NPI: 1962981126
Provider Name (Legal Business Name): KAILYN SLACK NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2018
Last Update Date: 10/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5185 OLD NATIONAL HWY
ATLANTA GA
30349-3244
US

IV. Provider business mailing address

1205 METROPOLITAN AVE SE APT 333
ATLANTA GA
30316-1987
US

V. Phone/Fax

Practice location:
  • Phone: 404-763-9300
  • Fax:
Mailing address:
  • Phone: 478-396-1147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN227754
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberRN22754
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN227754
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: