Provider Demographics
NPI:1164497178
Name:SLACK, ANGELIA DAWN (CRNA)
Entity Type:Individual
Prefix:
First Name:ANGELIA
Middle Name:DAWN
Last Name:SLACK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:740-446-5227
Mailing Address - Fax:740-441-8058
Practice Address - Street 1:90 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:740-446-5227
Practice Address - Fax:740-441-8058
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4064A367500000X
OHCOA.06914-NA367500000X
WV36798367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2605057000Medicaid
OH2240702Medicaid
000000223446OtherANTHEM BCBS
001714140OtherMOUNTAIN STATE BCBS
OH000000204799OtherOH MEDICAID UNISON
OH430073754OtherRR MEDICARE
000000223446OtherANTHEM BCBS