Provider Demographics
NPI:1619212438
Name:PIPKIN, IRENE AGNES
Entity Type:Individual
Prefix:MRS
First Name:IRENE
Middle Name:AGNES
Last Name:PIPKIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:IRENE
Other - Middle Name:AGNES
Other - Last Name:ARAGON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:30612 PEANUTS CT
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-9132
Mailing Address - Country:US
Mailing Address - Phone:907-262-0423
Mailing Address - Fax:907-260-3383
Practice Address - Street 1:30612 PEANUTS CT
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-9132
Practice Address - Country:US
Practice Address - Phone:907-262-0423
Practice Address - Fax:907-260-3383
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-05
Last Update Date:2016-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1636563Medicaid