Basic Information
| Provider Information | |||||||||
| NPI: | 1073780441 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLATER | ||||||||
| FirstName: | MISTY | ||||||||
| MiddleName: | D | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACOBS | ||||||||
| OtherFirstName: | MISTY | ||||||||
| OtherMiddleName: | D | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 38 | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373340038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9312274984 | ||||||||
| FaxNumber: | 9312274985 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 SIVLEY RD SW | ||||||||
| Address2: | |||||||||
| City: | HUNTSVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 358014421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2562651000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 07/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 01065155A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 53750 | TN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD.38961 | AL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.