Provider Demographics
NPI:1942734850
Name:POULSEN, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:POULSEN
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 70
Mailing Address - Street 2:
Mailing Address - City:TOGIAK
Mailing Address - State:AK
Mailing Address - Zip Code:99678-0070
Mailing Address - Country:US
Mailing Address - Phone:907-493-5511
Mailing Address - Fax:907-493-5311
Practice Address - Street 1:101 1ST AVE
Practice Address - Street 2:
Practice Address - City:TOGIAK
Practice Address - State:AK
Practice Address - Zip Code:99678
Practice Address - Country:US
Practice Address - Phone:907-493-5511
Practice Address - Fax:907-493-5311
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17-1432-I172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker