Healthcare Provider Details

I. General information

NPI: 1891045209
Provider Name (Legal Business Name): ELIZABETH SLATES CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/12/2012
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5175 MORSE RD STE 300
GAHANNA OH
43230-3458
US

IV. Provider business mailing address

5175 MORSE RD STE 300
GAHANNA OH
43230-3458
US

V. Phone/Fax

Practice location:
  • Phone: 614-476-4101
  • Fax: 614-476-4101
Mailing address:
  • Phone: 614-476-4101
  • Fax: 614-476-4101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN.13635
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number318633
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: