Provider Demographics
NPI:1417404815
Name:NELSON, DIANE (CHA)
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:NELSON
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 70
Mailing Address - Street 2:
Mailing Address - City:KOYUK
Mailing Address - State:AK
Mailing Address - Zip Code:99753-0070
Mailing Address - Country:US
Mailing Address - Phone:907-963-3311
Mailing Address - Fax:907-963-3610
Practice Address - Street 1:EAST 2ND AVE
Practice Address - Street 2:RUTH QUAMIIGGAN HENERY MEMORIAL CLINIC
Practice Address - City:KOYUK
Practice Address - State:AK
Practice Address - Zip Code:99753-0070
Practice Address - Country:US
Practice Address - Phone:907-963-3311
Practice Address - Fax:907-963-3610
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-02
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCHAOtherCHA