Provider Demographics
NPI:1346508538
Name:STONEBREAKER, SELMA JANE (PDHA II)
Entity type:Individual
Prefix:
First Name:SELMA
Middle Name:JANE
Last Name:STONEBREAKER
Suffix:
Gender:F
Credentials:PDHA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 TONGASS DR
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-9416
Mailing Address - Country:US
Mailing Address - Phone:907-966-8343
Mailing Address - Fax:907-966-8663
Practice Address - Street 1:222 TONGASS DR
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-9416
Practice Address - Country:US
Practice Address - Phone:907-966-8343
Practice Address - Fax:907-966-8663
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK11-069-PDHAIIOtherCOMMUNITY HEALTH AIDE PROGRAM CERTIFICATION BOARD - FEDERAL CERTIFICATION