Provider Demographics
NPI:1922246503
Name:SLATE, COLLEEN M (NP)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:SLATE
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2331 FRANKLIN RD SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1111
Practice Address - Country:US
Practice Address - Phone:540-224-5170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-04
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001134247163W00000X
AK149755363LF0000X
VA0024168258363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1922246503Medicaid
VA541586601118OtherTRICARE/CHAMPUS
VAP01051629OtherRAILROAD MEDICARE
VA1922246503OtherVA PREMIER
VA1922246503OtherAETNA
VA1922246503OtherANTHEM MEDIGAP
VA1922246503OtherVA PREMIER