Provider Demographics
NPI:1629254917
Name:SMAW, KISHA DIANNE (BACHELORS)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:DIANNE
Last Name:SMAW
Suffix:
Gender:F
Credentials:BACHELORS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1550 E 74TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507
Mailing Address - Country:US
Mailing Address - Phone:907-929-5826
Mailing Address - Fax:907-929-5862
Practice Address - Street 1:1550 E 74TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507
Practice Address - Country:US
Practice Address - Phone:907-929-5826
Practice Address - Fax:907-929-5862
Is Sole Proprietor?:No
Enumeration Date:2008-01-16
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK731680171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM5542Medicaid