Provider Demographics
NPI:1053653691
Name:KOOZAATA, CHANNA LISA
Entity Type:Individual
Prefix:
First Name:CHANNA
Middle Name:LISA
Last Name:KOOZAATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 GRAVEL ROAD
Mailing Address - Street 2:
Mailing Address - City:GAMBELL
Mailing Address - State:AK
Mailing Address - Zip Code:99742-0190
Mailing Address - Country:US
Mailing Address - Phone:907-985-5012
Mailing Address - Fax:907-985-5085
Practice Address - Street 1:190 GRAVEL ROAD
Practice Address - Street 2:
Practice Address - City:GAMBELL
Practice Address - State:AK
Practice Address - Zip Code:99742-0190
Practice Address - Country:US
Practice Address - Phone:907-985-5012
Practice Address - Fax:907-985-5085
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK10-1073-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK10-1073-IIIOtherCHA III