Basic Information
| Provider Information | |||||||||
| NPI: | 1689941163 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEXTER | ||||||||
| FirstName: | ESTHER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TICKETT | ||||||||
| OtherFirstName: | ESTHER | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CHA II | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | #3 ADAMS LANDING-OLD | ||||||||
| Address2: | P.O BOX 180 | ||||||||
| City: | SELAWIK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997700180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074842199 | ||||||||
| FaxNumber: | 9074842119 | ||||||||
| Practice Location | |||||||||
| Address1: | # 3 ADAMS LANDING-OLD | ||||||||
| Address2: | |||||||||
| City: | SELAWIK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997700180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074842199 | ||||||||
| FaxNumber: | 9074842119 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 11/28/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 10-1056-II | AK | Y | Other Service Providers | Community Health Worker |
No ID Information.