Provider Demographics
NPI:1619540457
Name:LY, PAUL (LPN)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:LY
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8432 CREEK FRONT DR
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-1521
Mailing Address - Country:US
Mailing Address - Phone:907-313-9894
Mailing Address - Fax:
Practice Address - Street 1:670 W FIREWEED LN STE 160
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2561
Practice Address - Country:US
Practice Address - Phone:907-770-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK121358164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse