Provider Demographics
NPI:1003840232
Name:SLACK, KRISTI M (CF NP)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:M
Last Name:SLACK
Suffix:
Gender:F
Credentials:CF NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 56
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:MS
Mailing Address - Zip Code:38856-0056
Mailing Address - Country:US
Mailing Address - Phone:662-728-2408
Mailing Address - Fax:662-728-2409
Practice Address - Street 1:3 COUNTY ROAD 4050
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:MS
Practice Address - Zip Code:38856
Practice Address - Country:US
Practice Address - Phone:662-728-2408
Practice Address - Fax:662-728-2409
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR853095363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00239247Medicaid
MS00239247Medicaid