Provider Demographics
NPI:1417510223
Name:SLATER, JUSTINE
Entity Type:Individual
Prefix:MRS
First Name:JUSTINE
Middle Name:
Last Name:SLATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JUSTINE
Other - Middle Name:
Other - Last Name:BATES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 71248
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-1248
Mailing Address - Country:US
Mailing Address - Phone:907-452-4222
Mailing Address - Fax:
Practice Address - Street 1:710 3RD AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4455
Practice Address - Country:US
Practice Address - Phone:907-452-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-17
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020977Medicaid