Provider Demographics
NPI:1295045508
Name:EGGLESTON, KELLY (BACHLOR OF ARTS ED)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:EGGLESTON
Suffix:
Gender:F
Credentials:BACHLOR OF ARTS ED
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 56597
Mailing Address - Street 2:
Mailing Address - City:NORTH POLE
Mailing Address - State:AK
Mailing Address - Zip Code:99705
Mailing Address - Country:US
Mailing Address - Phone:907-460-1414
Mailing Address - Fax:
Practice Address - Street 1:764 ADVENTURE ROAD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712
Practice Address - Country:US
Practice Address - Phone:907-460-1414
Practice Address - Fax:907-488-2652
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-20
Last Update Date:2010-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator