Provider Demographics
NPI:1285456947
Name:SLADE, AUDREY A
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:A
Last Name:SLADE
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 1:2951 E DARTMOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-6907
Mailing Address - Country:US
Mailing Address - Phone:480-326-9942
Mailing Address - Fax:
Practice Address - Street 1:2951 E DARTMOUTH ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85213-6907
Practice Address - Country:US
Practice Address - Phone:480-326-9942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-24
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation SpecialistGroup - Multi-Specialty