Provider Demographics
NPI:1730323429
Name:MCMULLEN, CHARLEMAGNE MARIE (CHP-C)
Entity Type:Individual
Prefix:MRS
First Name:CHARLEMAGNE
Middle Name:MARIE
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials:CHP-C
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 8023
Mailing Address - Street 2:
Mailing Address - City:NANWALEK
Mailing Address - State:AK
Mailing Address - Zip Code:99603-6623
Mailing Address - Country:US
Mailing Address - Phone:907-281-2250
Mailing Address - Fax:907-281-2244
Practice Address - Street 1:8023 MAIN STREET
Practice Address - Street 2:
Practice Address - City:NANWALEK
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-224-4908
Practice Address - Fax:907-224-5870
Is Sole Proprietor?:No
Enumeration Date:2009-04-24
Last Update Date:2012-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK07-937-P172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDH0190Medicaid