Provider Demographics
NPI:1477053965
Name:FINE, JUSTINE M
Entity Type:Individual
Prefix:MISS
First Name:JUSTINE
Middle Name:M
Last Name:FINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 N PIONEER PEAK DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-5924
Mailing Address - Country:US
Mailing Address - Phone:907-841-3463
Mailing Address - Fax:
Practice Address - Street 1:1414 N PIONEER PEAK DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-5924
Practice Address - Country:US
Practice Address - Phone:907-841-3463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101258310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility