Provider Demographics
NPI:1639786437
Name:SLATER, KISHA (INDEPENDENT PROVIDER)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:SLATER
Suffix:
Gender:F
Credentials:INDEPENDENT PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 W DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43610-1310
Mailing Address - Country:US
Mailing Address - Phone:419-277-0559
Mailing Address - Fax:
Practice Address - Street 1:519 W DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43610-1310
Practice Address - Country:US
Practice Address - Phone:419-277-0559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-25
Last Update Date:2022-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRS619850172A00000X, 347C00000X
376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
No172A00000XOther Service ProvidersDriver
No376J00000XNursing Service Related ProvidersHomemaker