=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700696416
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STARLA RENEA SLAY CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/14/2025
-----------------------------------------------------
Last Update Date | 01/14/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 N EDWARDS ST
-----------------------------------------------------
City | ENTERPRISE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36330-2584
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-347-0584
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 THRUSH LN
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36303-1430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-885-0030
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-159598
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------