Provider Demographics
NPI:1730665050
Name:KNOWLTON, MARY LEE
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LEE
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:LEE
Other - Last Name:KNOWLTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MARY MORGAN
Mailing Address - Street 1:7521 BRAYTON DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99507-2667
Mailing Address - Country:US
Mailing Address - Phone:907-929-5826
Mailing Address - Fax:
Practice Address - Street 1:7521 BRAYTON DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99507-2667
Practice Address - Country:US
Practice Address - Phone:907-929-5826
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-19
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1636112Medicaid