Provider Demographics
NPI:1356000889
Name:KASHEVAROF, MELONIE MARIE (CHA)
Entity Type:Individual
Prefix:
First Name:MELONIE
Middle Name:MARIE
Last Name:KASHEVAROF
Suffix:
Gender:F
Credentials:CHA
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 8029
Mailing Address - Street 2:
Mailing Address - City:CHENEGA BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99574-8029
Mailing Address - Country:US
Mailing Address - Phone:907-573-5129
Mailing Address - Fax:907-573-5148
Practice Address - Street 1:625 MAIN STREET
Practice Address - Street 2:
Practice Address - City:CHENEGA BAY
Practice Address - State:AK
Practice Address - Zip Code:99574-8029
Practice Address - Country:US
Practice Address - Phone:907-573-5129
Practice Address - Fax:907-573-5148
Is Sole Proprietor?:No
Enumeration Date:2021-12-13
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker