Provider Demographics
NPI:1073704433
Name:MCGAHAN, HEDY LEANN
Entity type:Individual
Prefix:
First Name:HEDY
Middle Name:LEANN
Last Name:MCGAHAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEDY
Other - Middle Name:LEANN
Other - Last Name:REYNOLDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 8324
Mailing Address - Street 2:
Mailing Address - City:NIKISKI
Mailing Address - State:AK
Mailing Address - Zip Code:99635-8324
Mailing Address - Country:US
Mailing Address - Phone:907-252-7654
Mailing Address - Fax:866-431-3260
Practice Address - Street 1:50135 TERRY RAY AVE.
Practice Address - Street 2:
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611
Practice Address - Country:US
Practice Address - Phone:907-260-9469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-09
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM75121Medicaid