Provider Demographics
NPI:1114534179
Name:COBEN-HALL, DONNA RENEE
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:RENEE
Last Name:COBEN-HALL
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 1:570 RIVERSTONE WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-2940
Mailing Address - Country:US
Mailing Address - Phone:907-458-8633
Mailing Address - Fax:907-458-8622
Practice Address - Street 1:570 RIVERSTONE WAY
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-2940
Practice Address - Country:US
Practice Address - Phone:907-687-8316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK164106225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1598942807Medicaid