Basic Information
| Provider Information | |||||||||
| NPI: | 1447421227 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILLER | ||||||||
| FirstName: | AGNES | ||||||||
| MiddleName: | I | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CHP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MEGANACK | ||||||||
| OtherFirstName: | AGNES | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 5530 | ||||||||
| Address2: | |||||||||
| City: | PORT GRAHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996035530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072842241 | ||||||||
| FaxNumber: | 9072842277 | ||||||||
| Practice Location | |||||||||
| Address1: | 5530 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | PORT GRAHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996035530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072842241 | ||||||||
| FaxNumber: | 9072842277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2008 | ||||||||
| LastUpdateDate: | 12/13/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | AK | Y | Other Service Providers | Community Health Worker |
No ID Information.