Basic Information
| Provider Information | |||||||||
| NPI: | 1295365732 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATELNIKOFF | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3290 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8669071068 | ||||||||
| FaxNumber: | 4259179141 | ||||||||
| Practice Location | |||||||||
| Address1: | 717 E REZANOF DR | ||||||||
| Address2: | |||||||||
| City: | KODIAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996156416 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074812400 | ||||||||
| FaxNumber: | 9074812419 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2020 | ||||||||
| LastUpdateDate: | 01/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/23/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | AK | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.