Provider Demographics
NPI:1922665132
Name:PETKOVA, YELENA
Entity Type:Individual
Prefix:
First Name:YELENA
Middle Name:
Last Name:PETKOVA
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 1:607 OLD STEESE HWY STE B176
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-3163
Mailing Address - Country:US
Mailing Address - Phone:907-457-1158
Mailing Address - Fax:907-457-1198
Practice Address - Street 1:270 FAIRHILL RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99712-1614
Practice Address - Country:US
Practice Address - Phone:907-457-1158
Practice Address - Fax:907-457-1198
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator