Provider Demographics
NPI:1811787377
Name:WONGITTILIN, LARA J (CHA-T)
Entity type:Individual
Prefix:
First Name:LARA
Middle Name:J
Last Name:WONGITTILIN
Suffix:
Gender:F
Credentials:CHA-T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 GREG KRUSHEK AVE
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-0966
Mailing Address - Country:US
Mailing Address - Phone:907-443-3311
Mailing Address - Fax:907-443-3471
Practice Address - Street 1:PO BOX 151
Practice Address - Street 2:
Practice Address - City:SAVOONGA
Practice Address - State:AK
Practice Address - Zip Code:99769-0151
Practice Address - Country:US
Practice Address - Phone:907-984-6513
Practice Address - Fax:907-984-6068
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-08
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker