Provider Demographics
NPI:1710649041
Name:MINA, LEA G
Entity Type:Individual
Prefix:
First Name:LEA
Middle Name:G
Last Name:MINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7940 LADASA PL
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-3052
Mailing Address - Country:US
Mailing Address - Phone:907-771-4029
Mailing Address - Fax:907-743-3061
Practice Address - Street 1:7940 LADASA PL
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-3052
Practice Address - Country:US
Practice Address - Phone:907-771-4029
Practice Address - Fax:907-743-3061
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1014383104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness