Provider Demographics
NPI:1003125493
Name:LLANEZA, MERLO ISANG SR
Entity Type:Individual
Prefix:MR
First Name:MERLO
Middle Name:ISANG
Last Name:LLANEZA
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 BETULA CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-4126
Mailing Address - Country:US
Mailing Address - Phone:907-382-5040
Mailing Address - Fax:907-522-0564
Practice Address - Street 1:1609 BETULA CIR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-4126
Practice Address - Country:US
Practice Address - Phone:907-382-5040
Practice Address - Fax:907-522-0564
Is Sole Proprietor?:No
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK100875374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK6522461Medicaid