Basic Information
| Provider Information | |||||||||
| NPI: | 1477556488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYGREN | ||||||||
| FirstName: | ANNELLE | ||||||||
| MiddleName: | GLEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3100 CHANNEL DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017837 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074634074 | ||||||||
| FaxNumber: | 9074631510 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 COLD STORAGE ROAD | ||||||||
| Address2: | |||||||||
| City: | CRAIG | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077554967 | ||||||||
| FaxNumber: | 9077552414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2005 | ||||||||
| LastUpdateDate: | 11/07/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 12333T | CA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2964T | OR | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 297 | AK | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1023212 | 05 | AK | MEDICAID | OPTT297 | 01 | AK | STATE OF ALASKA | OTHER |