Provider Demographics
NPI:1063843233
Name:NELSON, GRACIE (CASE MANAGER)
Entity Type:Individual
Prefix:MISS
First Name:GRACIE
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:MISS
Other - First Name:GRACIE
Other - Middle Name:
Other - Last Name:KAMEROFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3266
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-3266
Mailing Address - Country:US
Mailing Address - Phone:907-543-6173
Mailing Address - Fax:907-543-6159
Practice Address - Street 1:700 CHEIF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-7000
Practice Address - Country:US
Practice Address - Phone:907-543-6173
Practice Address - Fax:907-543-6159
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid