Provider Demographics
NPI:1295261261
Name:SLAGLE, KRISTY
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
Last Name:SLAGLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:97 ROOSEVELT PL
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-3020
Mailing Address - Country:US
Mailing Address - Phone:516-426-2325
Mailing Address - Fax:718-779-2070
Practice Address - Street 1:97 ROOSEVELT PL
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3020
Practice Address - Country:US
Practice Address - Phone:516-426-2325
Practice Address - Fax:718-779-2070
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist