Provider Demographics
NPI:1629349428
Name:ROLL, LORETTA DARLENE (CHA I V)
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:DARLENE
Last Name:ROLL
Suffix:
Gender:F
Credentials:CHA I V
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 E INTERNATIONAL AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-1408
Mailing Address - Country:US
Mailing Address - Phone:907-276-2700
Mailing Address - Fax:907-279-4351
Practice Address - Street 1:34 LAVELLE COURT
Practice Address - Street 2:
Practice Address - City:UNALASKA
Practice Address - State:AK
Practice Address - Zip Code:99685-1130
Practice Address - Country:US
Practice Address - Phone:907-581-2742
Practice Address - Fax:907-581-2006
Is Sole Proprietor?:No
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK17212345Medicaid