Provider Demographics
NPI:1740999804
Name:SLATER, TINA MARIE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:SLATER
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 1:633 W BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692
Mailing Address - Country:US
Mailing Address - Phone:740-978-3657
Mailing Address - Fax:
Practice Address - Street 1:633 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-1135
Practice Address - Country:US
Practice Address - Phone:740-978-3657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-17
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRP118602OtherDRIVERS LICENSE