Basic Information
Provider Information | |||||||||
NPI: | 1558493866 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NEMIRE | ||||||||
FirstName: | MISTY | ||||||||
MiddleName: | BLUE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | NEMIRE | ||||||||
OtherFirstName: | MISTY | ||||||||
OtherMiddleName: | BLUE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CNA | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2950 TONGASS AVE. | ||||||||
Address2: | SUITE 403 | ||||||||
City: | KETCHIKAN | ||||||||
State: | AK | ||||||||
PostalCode: | 99901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072284902 | ||||||||
FaxNumber: | 9072285256 | ||||||||
Practice Location | |||||||||
Address1: | 2950 TONGASS AVE. | ||||||||
Address2: | SUITE 403 | ||||||||
City: | KETCHIKAN | ||||||||
State: | AK | ||||||||
PostalCode: | 99901 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9072284902 | ||||||||
FaxNumber: | 9072285256 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/12/2007 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 376K00000X | 7847 | AK | Y |   | Nursing Service Related Providers | Nurse's Aide |   |
ID Information
ID | Type | State | Issuer | Description | 7847 | 01 | AK | CERTIFIED NURSE AIDE | OTHER |