Basic Information
| Provider Information | |||||||||
| NPI: | 1689942484 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TUNGUING | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TUNGUING | ||||||||
| OtherFirstName: | CHERYL | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 130 | ||||||||
| Address2: | |||||||||
| City: | DILLINGHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995760130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078425201 | ||||||||
| FaxNumber: | 9078429250 | ||||||||
| Practice Location | |||||||||
| Address1: | 6000 KANAKANAK RD | ||||||||
| Address2: | |||||||||
| City: | DILLINGHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995760130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078425201 | ||||||||
| FaxNumber: | 9078429250 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2011 | ||||||||
| LastUpdateDate: | 02/17/2021 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | 1576488 | 05 | AK | MEDICAID |