Provider Demographics
NPI:1003561770
Name:SAGOONICK, EMMALEIGH S (CHA-T)
Entity Type:Individual
Prefix:
First Name:EMMALEIGH
Middle Name:S
Last Name:SAGOONICK
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:PO BOX 966
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 1:1ST MAIN STREET
Practice Address - Street 2:
Practice Address - City:SHAKTOOLIK
Practice Address - State:AK
Practice Address - Zip Code:99771-0009
Practice Address - Country:US
Practice Address - Phone:907-955-3311
Practice Address - Fax:907-955-2342
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020820OtherCHA-T