Provider Demographics
NPI:1326735614
Name:SLADE, INGA BRIANNE
Entity Type:Individual
Prefix:
First Name:INGA
Middle Name:BRIANNE
Last Name:SLADE
Suffix:
Gender:F
Credentials:
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 86537
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85754-6537
Mailing Address - Country:US
Mailing Address - Phone:520-721-1887
Mailing Address - Fax:520-407-5338
Practice Address - Street 1:944 N DESERT AVE APT C
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2039
Practice Address - Country:US
Practice Address - Phone:801-403-3783
Practice Address - Fax:520-407-5338
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ12226141171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor