1619460862 NPI number — SHELLIE LEIGH MARTIN COMMUNITY HEALTH WOR

Table of content: SHELLIE LEIGH MARTIN COMMUNITY HEALTH WOR (NPI 1619460862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619460862 NPI number — SHELLIE LEIGH MARTIN COMMUNITY HEALTH WOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MARTIN
Provider First Name:
SHELLIE
Provider Middle Name:
LEIGH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COMMUNITY HEALTH WOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1619460862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 149
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OUZINKIE
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99644-0149
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-486-1389
Provider Business Mailing Address Fax Number:
907-680-2292

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OUZINKIE
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-486-1389
Provider Business Practice Location Address Fax Number:
907-680-2292
Provider Enumeration Date:
06/12/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 172V00000X , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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