MEDICARE: MS. JERRI SUSAN SLADE STNA

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	376K00000X	Nurse's Aide	324729040213	OH

General Provider Information

NPI Number	:	1770963167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JERRI SUSAN SLADE STNA

Provider Business Mailing Address
First Line	:	2123 WADSWORTH DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-3942
Country	:	US
Telephone Number	:	614-231-8725
Fax Number	:

Provider Business Practice Location Address
First Line	:	2123 WADSWORTH DR
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43232-3942
Country	:	US
Telephone Number	:	614-231-8725
Fax Number	:

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

Provider Enumeration Date	:	06/01/2015
Last Update Date	:	06/01/2015

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