Provider Demographics
NPI:1407940760
Name:AVALON, J. DETTE (MSN, ANP)
Entity Type:Individual
Prefix:MS
First Name:J.
Middle Name:DETTE
Last Name:AVALON
Suffix:
Gender:F
Credentials:MSN, ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3524 EAST 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508
Mailing Address - Country:US
Mailing Address - Phone:907-222-6601
Mailing Address - Fax:902-222-6602
Practice Address - Street 1:3524 EAST 15TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-222-6601
Practice Address - Fax:907-222-6602
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK308363L00000X, 363LF0000X
AK944363L00000X, 364SH1100X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SH1100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistHolistic