Provider Demographics
NPI:1508052820
Name:SOLESBEE, SERENA ROSE
Entity Type:Individual
Prefix:MRS
First Name:SERENA
Middle Name:ROSE
Last Name:SOLESBEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SERENA
Other - Middle Name:ROSE
Other - Last Name:DEMIENTIEFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:ATTN: BH DD SERVICES
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-543-2762
Mailing Address - Fax:907-543-3152
Practice Address - Street 1:460 RIDGECREST DRIVE
Practice Address - Street 2:SUITE 215
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-543-2762
Practice Address - Fax:907-543-3152
Is Sole Proprietor?:No
Enumeration Date:2007-09-20
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK10004541Medicaid