Provider Demographics
NPI:1164630042
Name:SMALL, AUDREY EILEEN (CNM)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:EILEEN
Last Name:SMALL
Suffix:
Gender:F
Credentials:CNM
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 5098
Mailing Address - Street 2:
Mailing Address - City:KETCHIKAN
Mailing Address - State:AK
Mailing Address - Zip Code:99901-0033
Mailing Address - Country:US
Mailing Address - Phone:907-225-1231
Mailing Address - Fax:907-247-1231
Practice Address - Street 1:355 CARLANNA LAKE RD LOWR
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5614
Practice Address - Country:US
Practice Address - Phone:907-225-1231
Practice Address - Fax:907-247-1231
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK524176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNM5982Medicaid
AKNM5982Medicaid