Provider Demographics
NPI:1619244100
Name:LOFGREEN, ANN MARIE
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:LOFGREEN
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:PO BOX 879382
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-9382
Mailing Address - Country:US
Mailing Address - Phone:907-414-5803
Mailing Address - Fax:888-241-1318
Practice Address - Street 1:432 S ALASKA ST
Practice Address - Street 2:
Practice Address - City:PALMER
Practice Address - State:AK
Practice Address - Zip Code:99645-6338
Practice Address - Country:US
Practice Address - Phone:907-414-5803
Practice Address - Fax:888-241-1318
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK107273174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK12503896OtherCAQH