Provider Demographics
NPI:1154698074
Name:LINCOLN, IDA E (CHA III)
Entity type:Individual
Prefix:
First Name:IDA
Middle Name:E
Last Name:LINCOLN
Suffix:
Gender:F
Credentials:CHA III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 29
Mailing Address - Street 2:1 SOW JOHN RD
Mailing Address - City:WHITE MOUNTAIN
Mailing Address - State:AK
Mailing Address - Zip Code:99784-0029
Mailing Address - Country:US
Mailing Address - Phone:907-638-3311
Mailing Address - Fax:907-638-2007
Practice Address - Street 1:1 SOW JOHN RD
Practice Address - Street 2:
Practice Address - City:WHITE MOUNTAIN
Practice Address - State:AK
Practice Address - Zip Code:99784-0029
Practice Address - Country:US
Practice Address - Phone:907-638-3311
Practice Address - Fax:907-638-2007
Is Sole Proprietor?:No
Enumeration Date:2011-11-21
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-1131-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKHEALTH AIDEOther111-1131-III