Provider Demographics
NPI:1558747873
Name:CARLOS, KEILYN MARGARET (CHA III)
Entity Type:Individual
Prefix:MISS
First Name:KEILYN
Middle Name:MARGARET
Last Name:CARLOS
Suffix:
Gender:F
Credentials:CHA III
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 195
Mailing Address - Street 2:
Mailing Address - City:TOGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99678-0195
Mailing Address - Country:US
Mailing Address - Phone:907-717-4474
Mailing Address - Fax:
Practice Address - Street 1:HALF MILE AIRPORT RD
Practice Address - Street 2:
Practice Address - City:TOGIAK
Practice Address - State:AK
Practice Address - Zip Code:99678-0195
Practice Address - Country:US
Practice Address - Phone:907-717-4474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-10
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK14-1305-111172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker