Provider Demographics
NPI:1659572949
Name:SLACK, ARMANDO WAYNE (RN)
Entity Type:Individual
Prefix:
First Name:ARMANDO
Middle Name:WAYNE
Last Name:SLACK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:MANNY
Other - Middle Name:WAYNE
Other - Last Name:SLACK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN
Mailing Address - Street 1:190 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84014-2832
Mailing Address - Country:US
Mailing Address - Phone:801-614-8400
Mailing Address - Fax:
Practice Address - Street 1:190 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:UT
Practice Address - Zip Code:84014
Practice Address - Country:US
Practice Address - Phone:801-614-8400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-31
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT2943543102163WA0400X, 163WX0200X
UT2943544405363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No163WX0200XNursing Service ProvidersRegistered NurseOncology