Provider Demographics
NPI:1780243048
Name:SLATTERY, COLLEEN MARIE (PA-C)
Entity type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:MARIE
Last Name:SLATTERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4501 NE 21ST LN
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4712
Mailing Address - Country:US
Mailing Address - Phone:954-802-8823
Mailing Address - Fax:
Practice Address - Street 1:4501 NE 21ST LN
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4712
Practice Address - Country:US
Practice Address - Phone:954-802-8823
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program