Individual
CHEYENNE SLACK
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LPN
Contact information
Practice address
23 BRITTANY CT, NORTHPORT, NY 11768-3225
(631) 834-5420
Mailing address
1308 N PARK AVE, BAY SHORE, NY 11706-4108
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
340734
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
12345678
12345678
—
01
—
340734
NEW YORK
NY
Enumeration date
02/05/2021
Last updated
09/27/2021
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