Basic Information
| Provider Information | |||||||||
| NPI: | 1164653838 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WOOD | ||||||||
| FirstName: | MANDY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CHA IV | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8023 | ||||||||
| Address2: | |||||||||
| City: | NANWALEK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996036623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072812250 | ||||||||
| FaxNumber: | 9072812244 | ||||||||
| Practice Location | |||||||||
| Address1: | 64834 NIKITA STREET | ||||||||
| Address2: | |||||||||
| City: | NANWALEK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996038023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072812250 | ||||||||
| FaxNumber: | 9072812244 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2009 | ||||||||
| LastUpdateDate: | 07/29/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
No ID Information.