Provider Demographics
NPI:1275255929
Name:GUMLICKPUK, IFTEKIA MARIE
Entity Type:Individual
Prefix:
First Name:IFTEKIA
Middle Name:MARIE
Last Name:GUMLICKPUK
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 5051
Mailing Address - Street 2:
Mailing Address - City:KOLIGANEK
Mailing Address - State:AK
Mailing Address - Zip Code:99576-5051
Mailing Address - Country:US
Mailing Address - Phone:907-596-6086
Mailing Address - Fax:
Practice Address - Street 1:CROSS THE CREEK ROAD
Practice Address - Street 2:
Practice Address - City:KOLIGANEK
Practice Address - State:AK
Practice Address - Zip Code:99576-9957
Practice Address - Country:US
Practice Address - Phone:907-596-6086
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7561344172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK7561344Medicaid