Provider Demographics
NPI:1396231288
Name:POULOS, MERCEDES RENEE (LPN)
Entity Type:Individual
Prefix:
First Name:MERCEDES
Middle Name:RENEE
Last Name:POULOS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 W FIREWEED LN STE 105
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-2044
Mailing Address - Country:US
Mailing Address - Phone:907-865-9653
Mailing Address - Fax:
Practice Address - Street 1:121 W FIREWEED LN STE 105
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2044
Practice Address - Country:US
Practice Address - Phone:907-865-9653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK134862164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse