Basic Information
Provider Information | |||||||||
NPI: | 1730446188 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MOLER | ||||||||
FirstName: | KIMBERLY | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PDHA II | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 605 | ||||||||
Address2: |   | ||||||||
City: | KAKE | ||||||||
State: | AK | ||||||||
PostalCode: | 998300605 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9077856542 | ||||||||
FaxNumber: | 9077853136 | ||||||||
Practice Location | |||||||||
Address1: | 101 TOTEM WAY | ||||||||
Address2: |   | ||||||||
City: | KAKE | ||||||||
State: | AK | ||||||||
PostalCode: | 99830 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9077856542 | ||||||||
FaxNumber: | 9077853136 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/23/2012 | ||||||||
LastUpdateDate: | 04/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 | 09-054-PDHAII | 01 | AK | COMMUNITY HEALTH AIDE PROGRAM CERTIFICATION BOARD - FEDERAL CERTIFICAITON | OTHER |