Provider Demographics
NPI:1962981126
Name:SLACK, KAILYN (NP)
Entity type:Individual
Prefix:
First Name:KAILYN
Middle Name:
Last Name:SLACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 METROPOLITAN AVE SE APT 333
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30316-1987
Mailing Address - Country:US
Mailing Address - Phone:478-396-1147
Mailing Address - Fax:
Practice Address - Street 1:5185 OLD NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30349-3244
Practice Address - Country:US
Practice Address - Phone:404-763-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN227754363LF0000X, 163WC0200X
GARN22754363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine