Provider Demographics
NPI:1417224106
Name:SMITH, CAROL L (CHP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:L
Last Name:SMITH
Suffix:
Gender:F
Credentials:CHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 29
Mailing Address - Street 2:
Mailing Address - City:WHITE MOUNTAIN
Mailing Address - State:AK
Mailing Address - Zip Code:99784-0029
Mailing Address - Country:US
Mailing Address - Phone:907-638-3311
Mailing Address - Fax:907-638-2007
Practice Address - Street 1:1 SCOW JOHN ROAD
Practice Address - Street 2:
Practice Address - City:WHITE MOUNTAIN
Practice Address - State:AK
Practice Address - Zip Code:99784-0029
Practice Address - Country:US
Practice Address - Phone:907-638-3311
Practice Address - Fax:907-638-2007
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK98-146-P172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK98-146-POtherCHP