Provider Demographics
NPI:1124310925
Name:HOMER, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:HOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 ABBOTT RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3443
Mailing Address - Country:US
Mailing Address - Phone:907-561-3313
Mailing Address - Fax:907-561-3315
Practice Address - Street 1:1750 ABBOTT RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3443
Practice Address - Country:US
Practice Address - Phone:907-561-3313
Practice Address - Fax:907-561-3315
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK920101736171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG736Medicaid