Healthcare Provider Details

I. General information

NPI: 1750936050
Provider Name (Legal Business Name): FAITH SLADE FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/05/2019
Last Update Date: 08/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S 4TH ST STE 600
FULTON NY
13069-2904
US

IV. Provider business mailing address

61 DELANO ST
PULASKI NY
13142-1400
US

V. Phone/Fax

Practice location:
  • Phone: 315-598-4790
  • Fax:
Mailing address:
  • Phone: 315-298-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number344906
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: