Provider Demographics
NPI:1407723059
Name:GOLOGERGEN-KIYUKLOOK, ETHEL JEAN
Entity type:Individual
Prefix:
First Name:ETHEL
Middle Name:JEAN
Last Name:GOLOGERGEN-KIYUKLOOK
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 966
Mailing Address - Street 2:
Mailing Address - City:NOME
Mailing Address - State:AK
Mailing Address - Zip Code:99762-0966
Mailing Address - Country:US
Mailing Address - Phone:907-443-3311
Mailing Address - Fax:907-443-8177
Practice Address - Street 1:1000 GREG KRUSCHEK AVE
Practice Address - Street 2:
Practice Address - City:NOME
Practice Address - State:AK
Practice Address - Zip Code:99762
Practice Address - Country:US
Practice Address - Phone:907-443-3311
Practice Address - Fax:907-443-8177
Is Sole Proprietor?:No
Enumeration Date:2025-10-20
Last Update Date:2025-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant