Provider Demographics
NPI:1528335007
Name:TICKETT, LOTTIE V I
Entity type:Individual
Prefix:MRS
First Name:LOTTIE
Middle Name:V
Last Name:TICKETT
Suffix:I
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:LOTTIE
Other - Middle Name:V
Other - Last Name:TICKETT
Other - Suffix:I
Other - Last Name Type:Former Name
Other - Credentials:CHP
Mailing Address - Street 1:80 BACK STREET
Mailing Address - Street 2:
Mailing Address - City:SHUNGNAK
Mailing Address - State:AK
Mailing Address - Zip Code:99773-0080
Mailing Address - Country:US
Mailing Address - Phone:907-437-2138
Mailing Address - Fax:907-437-2139
Practice Address - Street 1:80 BACK STREET
Practice Address - Street 2:
Practice Address - City:SHUNGNAK
Practice Address - State:AK
Practice Address - Zip Code:99773-0080
Practice Address - Country:US
Practice Address - Phone:907-437-2138
Practice Address - Fax:907-437-2139
Is Sole Proprietor?:No
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK00-019-P172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker