Provider Demographics
NPI:1730848904
Name:BLACK-SLAUGHTER, CHEYANNE
Entity type:Individual
Prefix:
First Name:CHEYANNE
Middle Name:
Last Name:BLACK-SLAUGHTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6775 SW 26TH AVE UNIT B
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97219-2193
Mailing Address - Country:US
Mailing Address - Phone:971-353-3207
Mailing Address - Fax:
Practice Address - Street 1:6775 SW 26TH AVE UNIT B
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97219-2193
Practice Address - Country:US
Practice Address - Phone:971-353-3207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-14
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR500797464374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR855162Medicaid