Basic Information
| Provider Information | |||||||||
| NPI: | 1912274564 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KATCHATAG | ||||||||
| FirstName: | LAVERNA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CHA-IV-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KRITZ | ||||||||
| OtherFirstName: | LAVERN | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 130 | ||||||||
| Address2: | |||||||||
| City: | DILLINGHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995760130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078425201 | ||||||||
| FaxNumber: | 9078425201 | ||||||||
| Practice Location | |||||||||
| Address1: | 189 AIRPORT ROAD | ||||||||
| Address2: | |||||||||
| City: | TOGIAK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99678 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074935511 | ||||||||
| FaxNumber: | 9074935511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 05/19/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 99-920-IV | AK | Y | Other Service Providers | Community Health Worker | 172V00000X | N | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | 99--920-IV | 01 | AK | CHA-IV-C | OTHER |