Provider Demographics
NPI:1073920260
Name:SLACK-GAY, DEBBIE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DEBBIE
Middle Name:
Last Name:SLACK-GAY
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 PUTNAM ST
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94509-5310
Mailing Address - Country:US
Mailing Address - Phone:559-903-5655
Mailing Address - Fax:
Practice Address - Street 1:1320 PUTNAM ST
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-5310
Practice Address - Country:US
Practice Address - Phone:559-903-5655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001268363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner