Basic Information
| Provider Information | |||||||||
| NPI: | 1609354224 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SLATE | ||||||||
| FirstName: | TALLEY | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7 WORKS WAY | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036924018 | ||||||||
| FaxNumber: | 8339442270 | ||||||||
| Practice Location | |||||||||
| Address1: | 7 WORKS WAY | ||||||||
| Address2: | |||||||||
| City: | SOMERSWORTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038781639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6036924018 | ||||||||
| FaxNumber: | 8339442270 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2018 | ||||||||
| LastUpdateDate: | 02/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 066113-23 | NH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3113557 | 05 | NH | MEDICAID |