Provider Demographics
NPI:1285991323
Name:MATTHIAS-OKITKUN, STACEY (CHA III)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:MATTHIAS-OKITKUN
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 1:50 AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:STEBBINS
Mailing Address - State:AK
Mailing Address - Zip Code:99671
Mailing Address - Country:US
Mailing Address - Phone:907-934-3311
Mailing Address - Fax:907-934-3312
Practice Address - Street 1:50 AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:STEBBINS
Practice Address - State:AK
Practice Address - Zip Code:99671
Practice Address - Country:US
Practice Address - Phone:907-934-3311
Practice Address - Fax:907-934-3312
Is Sole Proprietor?:No
Enumeration Date:2012-04-13
Last Update Date:2012-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK05-742-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK05-742-IIIOtherCHA III