Provider Demographics
NPI:1871861963
Name:TICKET, MAUREEN COLLEEN (CHP)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:COLLEEN
Last Name:TICKET
Suffix:
Gender:F
Credentials:CHP
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 180
Mailing Address - Street 2:
Mailing Address - City:SELAWIK
Mailing Address - State:AK
Mailing Address - Zip Code:99770-0180
Mailing Address - Country:US
Mailing Address - Phone:907-484-2199
Mailing Address - Fax:907-484-2119
Practice Address - Street 1:#3 ADAMS LANDING OLD
Practice Address - Street 2:
Practice Address - City:SELAWIK
Practice Address - State:AK
Practice Address - Zip Code:99770-0180
Practice Address - Country:US
Practice Address - Phone:907-484-2199
Practice Address - Fax:907-484-2119
Is Sole Proprietor?:No
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-1138-II172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker