Provider Demographics
NPI:1659498848
Name:COCONINO COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:COCONINO COUNTY HEALTH DEPARTMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STELLA LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:KYUNG-HEE
Authorized Official - Suffix:
Authorized Official - Credentials:PNP
Authorized Official - Phone:928-522-7920
Mailing Address - Street 1:2625 N KING ST
Mailing Address - Street 2:CLINICAL SERVICES
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004-1884
Mailing Address - Country:US
Mailing Address - Phone:928-522-7920
Mailing Address - Fax:928-522-7922
Practice Address - Street 1:2625 N KING ST
Practice Address - Street 2:CLINICAL SERVICES
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86004-1884
Practice Address - Country:US
Practice Address - Phone:928-522-7920
Practice Address - Fax:928-522-7922
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP1060251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ910431OtherAHCCCS
AZFL500Medicare ID - Type Unspecified