Provider Demographics
NPI:1790352243
Name:DIAZ, STEPHANIE DAVIS SLATER (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:DAVIS SLATER
Last Name:DIAZ
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:DAVIS
Other - Last Name:SLATER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:567 FRANKLIN ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02139-2923
Mailing Address - Country:US
Mailing Address - Phone:845-901-9211
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:
Practice Address - City:JAMAICA PLAIN
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-983-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-04
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2329699163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine