Provider Demographics
NPI:1659407617
Name:SLACK, CHRISTINE MARIE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:CHRISTINE
Middle Name:MARIE
Last Name:SLACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 E DUTCHMANS TRL
Mailing Address - Street 2:
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85218-4916
Mailing Address - Country:US
Mailing Address - Phone:480-983-2311
Mailing Address - Fax:
Practice Address - Street 1:3701 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:APACHE JUNCTION
Practice Address - State:AZ
Practice Address - Zip Code:85219-9301
Practice Address - Country:US
Practice Address - Phone:480-982-1110
Practice Address - Fax:480-288-0532
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP040169164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ178915OtherAHCCCS