Healthcare Provider Details

I. General information

NPI: 1689197717
Provider Name (Legal Business Name): MARY AGNES SLAVENS CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2017
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6505 MARKET ST
BOARDMAN OH
44512-3457
US

IV. Provider business mailing address

1 PERKINS SQ
AKRON OH
44308-1063
US

V. Phone/Fax

Practice location:
  • Phone: 330-480-2363
  • Fax: 330-480-6359
Mailing address:
  • Phone: 330-543-1205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License NumberAPRN.CNP.021235
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: