Healthcare Provider Details

I. General information

NPI: 1346579117
Provider Name (Legal Business Name): CRYSTAL DAWN SLAUGHTER APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

IV. Provider business mailing address

221 NE GLEN OAK AVE
PEORIA IL
61636-0001
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-5522
  • Fax:
Mailing address:
  • Phone: 309-672-5522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209007934
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number209007934
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: