Provider Demographics
NPI:1396073946
Name:SLATER, STEPHANIE GRACE (RN, CPNP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:GRACE
Last Name:SLATER
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9411 N LAMAR BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-4179
Mailing Address - Country:US
Mailing Address - Phone:512-744-6000
Mailing Address - Fax:512-334-1003
Practice Address - Street 1:9411 N LAMAR BLVD STE 120
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-4179
Practice Address - Country:US
Practice Address - Phone:512-744-6000
Practice Address - Fax:512-334-1003
Is Sole Proprietor?:No
Enumeration Date:2009-11-19
Last Update Date:2016-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX644868363LP0200X
TXAP110325363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX3535304-01Medicaid