Healthcare Provider Details

I. General information

NPI: 1659572949
Provider Name (Legal Business Name): ARMANDO WAYNE SLACK APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MANNY WAYNE SLACK APRN

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3780 S WEST TEMPLE STE 201
SOUTH SALT LAKE UT
84115-4464
US

IV. Provider business mailing address

2193 RIFLEMAN DR
FARMINGTON UT
84025-2792
US

V. Phone/Fax

Practice location:
  • Phone: 385-444-5800
  • Fax:
Mailing address:
  • Phone: 801-557-4257
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2943544405
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number2943543102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: