Healthcare Provider Details

I. General information

NPI: 1063790715
Provider Name (Legal Business Name): MANDY NICHOLE SLADKY B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 09/26/2022
Certification Date: 09/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 1ST ST NW
ALBUQUERQUE NM
87102-1529
US

IV. Provider business mailing address

PO BOX 25445
ALBUQUERQUE NM
87125-0445
US

V. Phone/Fax

Practice location:
  • Phone: 505-766-5197
  • Fax:
Mailing address:
  • Phone: 505-766-5197
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number63266
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: