MEDICARE: KENISHA SLADE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	338575	TX

General Provider Information

NPI Number	:	1073161477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENISHA SLADE

Provider Business Mailing Address
First Line	:	21 LAZY SWING CT
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578-1570
Country	:	US
Telephone Number	:	808-728-9240
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 LAZY SWING CT
Second Line	:
City	:	MANVEL
State	:	TX
Zip	:	77578-1570
Country	:	US
Telephone Number	:	808-728-9240
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/28/2019
Last Update Date	:	08/28/2019

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Directions to “ KENISHA SLADE ” Practice Location

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