Provider Demographics
NPI:1679831887
Name:GEORGE, ROBERTA LOUISE (PDHA I)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LOUISE
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PDHA I
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 69
Mailing Address - Street 2:
Mailing Address - City:KLAWOCK
Mailing Address - State:AK
Mailing Address - Zip Code:99925-0069
Mailing Address - Country:US
Mailing Address - Phone:907-755-4918
Mailing Address - Fax:907-755-4811
Practice Address - Street 1:7300 A KLAWOCK HOLLIS HIGHWAY
Practice Address - Street 2:
Practice Address - City:KLAWOCK
Practice Address - State:AK
Practice Address - Zip Code:99925
Practice Address - Country:US
Practice Address - Phone:907-755-4918
Practice Address - Fax:907-755-4811
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-25
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK11-071-PDHA IOtherCOMMUNITY HEALTH AIDE PROGRAM CERTIFICATION BOARD - FEDERAL CERTIFICAITON