Provider Demographics
NPI:1306283809
Name:NATHANIEL, MARY
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:NATHANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:PAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1717 COWLES ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-5926
Mailing Address - Country:US
Mailing Address - Phone:907-452-8251
Mailing Address - Fax:
Practice Address - Street 1:102 BELL ST
Practice Address - Street 2:
Practice Address - City:CHALKYITSIK
Practice Address - State:AK
Practice Address - Zip Code:99788
Practice Address - Country:US
Practice Address - Phone:907-848-8215
Practice Address - Fax:907-848-8696
Is Sole Proprietor?:No
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker