Provider Demographics
NPI:1083068241
Name:COFFEY-MILLIGROCK, DEYONNE
Entity Type:Individual
Prefix:
First Name:DEYONNE
Middle Name:
Last Name:COFFEY-MILLIGROCK
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:P.O. BOX 50
Mailing Address - Street 2:
Mailing Address - City:STEBBINS
Mailing Address - State:AK
Mailing Address - Zip Code:99671-0050
Mailing Address - Country:US
Mailing Address - Phone:907-934-3311
Mailing Address - Fax:907-934-3312
Practice Address - Street 1:50 SCHOOL BLVD
Practice Address - Street 2:
Practice Address - City:STEBBINS
Practice Address - State:AK
Practice Address - Zip Code:99671-0050
Practice Address - Country:US
Practice Address - Phone:907-934-3311
Practice Address - Fax:907-934-3312
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-14
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHAOtherCHA