Provider Demographics
NPI:1609354224
Name:SLATE, TALLEY E (APRN)
Entity Type:Individual
Prefix:
First Name:TALLEY
Middle Name:E
Last Name:SLATE
Suffix:
Gender:F
Credentials:APRN
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 412503
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-1639
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 MADBURY RD
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NH
Practice Address - Zip Code:03824-2021
Practice Address - Country:US
Practice Address - Phone:603-868-5080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-06
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH066113-23363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3113557Medicaid