Provider Demographics
NPI:1164911905
Name:STOVALL, SONJA A
Entity Type:Individual
Prefix:
First Name:SONJA
Middle Name:A
Last Name:STOVALL
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:PO BOX 80205
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99708-0205
Mailing Address - Country:US
Mailing Address - Phone:907-388-4772
Mailing Address - Fax:
Practice Address - Street 1:565 UNIVERSITY AVE STE 1
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3687
Practice Address - Country:US
Practice Address - Phone:907-456-8426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK124644225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist