Provider Demographics
NPI:1154538460
Name:SMITH, CAROLYN (RN)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 310
Mailing Address - Street 2:
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576-0310
Mailing Address - Country:US
Mailing Address - Phone:907-842-4139
Mailing Address - Fax:907-842-4106
Practice Address - Street 1:1500 KANAKANAK ROAD
Practice Address - Street 2:
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576-0310
Practice Address - Country:US
Practice Address - Phone:907-842-4139
Practice Address - Fax:907-842-4106
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCM 9533171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM 9533Medicaid