Healthcare Provider Details

I. General information

NPI: 1679950141
Provider Name (Legal Business Name): SHANNON RAE SLAYTON ATC, LAT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 N GRAND AVE
TAHLEQUAH OK
74464-2302
US

IV. Provider business mailing address

603 N GRAND AVE
TAHLEQUAH OK
74464-2302
US

V. Phone/Fax

Practice location:
  • Phone: 214-762-8109
  • Fax:
Mailing address:
  • Phone: 214-762-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number746
License Number StateOK

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: