Provider Demographics
NPI:1932503869
Name:ACTIVE, AQUILINA M
Entity Type:Individual
Prefix:
First Name:AQUILINA
Middle Name:M
Last Name:ACTIVE
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: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:MAQIQ STREET
Practice Address - Street 2:
Practice Address - City:NANWALEK
Practice Address - State:AK
Practice Address - Zip Code:99603-6623
Practice Address - Country:US
Practice Address - Phone:907-281-2250
Practice Address - Fax:907-281-2244
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker