Provider Demographics
NPI:1972789899
Name:DE LEON, CECILIA
Entity Type:Individual
Prefix:
First Name:CECILIA
Middle Name:
Last Name:DE LEON
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 1:500 E TUDOR RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99503-7368
Mailing Address - Country:US
Mailing Address - Phone:907-563-5002
Mailing Address - Fax:907-563-5047
Practice Address - Street 1:500 E TUDOR RD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-7368
Practice Address - Country:US
Practice Address - Phone:907-563-5002
Practice Address - Fax:907-563-5047
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2008-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK436948171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCMG911Medicaid