Basic Information
| Provider Information | |||||||||
| NPI: | 1700017472 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MORRISETT | ||||||||
| FirstName: | KYLA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CHP-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 172 | ||||||||
| Address2: | |||||||||
| City: | TATITLEK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996770172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073252235 | ||||||||
| FaxNumber: | 9073252350 | ||||||||
| Practice Location | |||||||||
| Address1: | 411 OLD VILLAGE ROAD | ||||||||
| Address2: | |||||||||
| City: | TATITLEK | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996770172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9073252235 | ||||||||
| FaxNumber: | 9073252350 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2009 | ||||||||
| LastUpdateDate: | 05/22/2012 | ||||||||
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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 | 172V00000X | Y | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | MDH0192 | 05 | AK | MEDICAID |