Provider Demographics
NPI:1669743589
Name:MALEMUTE, MARY (CHA III)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MALEMUTE
Suffix:
Gender:F
Credentials:CHA III
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:KOYUKUK
Mailing Address - State:AK
Mailing Address - Zip Code:99754
Mailing Address - Country:US
Mailing Address - Phone:907-927-2221
Mailing Address - Fax:
Practice Address - Street 1:100 SPRUCE ST
Practice Address - Street 2:
Practice Address - City:KOYUKUK
Practice Address - State:AK
Practice Address - Zip Code:99754
Practice Address - Country:US
Practice Address - Phone:907-927-2221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK11-1151-III172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker