Provider Demographics
NPI:1063535045
Name:COBURN, SALLY L (NP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:L
Last Name:COBURN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18828 MOOSE PL
Mailing Address - Street 2:
Mailing Address - City:CHUGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99567-6645
Mailing Address - Country:US
Mailing Address - Phone:907-854-8840
Mailing Address - Fax:
Practice Address - Street 1:3300 ARCTIC BLVD
Practice Address - Street 2:STE 101
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-4523
Practice Address - Country:US
Practice Address - Phone:907-561-3488
Practice Address - Fax:907-562-3488
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X, 133VN1201X
AK335363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1201XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Obesity and Weight Management