Basic Information
| Provider Information | |||||||||
| NPI: | 1134308356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TANANA CHIEFS CONFERENCE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHIEF ANDREW ISAAC HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1408 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1408 19TH AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997015903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074516682 | ||||||||
| FaxNumber: | 9074593976 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2007 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MALAMUTE | ||||||||
| AuthorizedOfficialFirstName: | LIZA | ||||||||
| AuthorizedOfficialMiddleName: | SARAH | ||||||||
| AuthorizedOfficialTitleorPosition: | DIABETES EDUCATOR/FOOT CARE NURSE | ||||||||
| AuthorizedOfficialTelephone: | 9074516682 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, CDE, CFCN | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | 17910 | AK | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.