Basic Information
| Provider Information | |||||||||
| NPI: | 1417224999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DOUGLAS | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CHP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 110 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | AMBLER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997860110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074452129 | ||||||||
| FaxNumber: | 9074452179 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | AMBLER | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997860110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074452129 | ||||||||
| FaxNumber: | 9074452179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
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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 | 171W00000X | 10-1057-II | AK | Y | Other Service Providers | Contractor |
No ID Information.