Healthcare Provider Details

I. General information

NPI: 1659386415
Provider Name (Legal Business Name): LARESHIA L SLADE ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LARESHIA L SLADE ARNP

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 06/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 CARAWAY CT 106
LARGO MD
20774-5461
US

IV. Provider business mailing address

PO BOX 6411
UPPER MARLBORO MD
20792-6411
US

V. Phone/Fax

Practice location:
  • Phone: 301-322-9500
  • Fax: 301-322-2227
Mailing address:
  • Phone: 301-322-9500
  • Fax: 301-322-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberARNP9208578
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier306946000
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: