Provider Demographics
NPI:1720162332
Name:PONCHIONE, ELAINE (ANP, RN, PSY A)
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
Last Name:PONCHIONE
Suffix:
Gender:F
Credentials:ANP, RN, PSY A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CUSHMAN ST
Mailing Address - Street 2:SUITE 3C
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4640
Mailing Address - Country:US
Mailing Address - Phone:907-455-7801
Mailing Address - Fax:907-455-7803
Practice Address - Street 1:250 CUSHMAN ST STE 3C
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4665
Practice Address - Country:US
Practice Address - Phone:907-455-7801
Practice Address - Fax:907-455-7803
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK491103TC1900X
AK4018163WP0808X
AK1045363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP6894Medicaid
AKK162139OtherMEDICARE PTAN