Provider Demographics
NPI:1720618853
Name:TENNIS, MICHELE K
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:K
Last Name:TENNIS
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 1:1401 S SEWARD MERIDIAN PKWY # ABC
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8312
Mailing Address - Country:US
Mailing Address - Phone:907-631-3520
Mailing Address - Fax:907-631-3634
Practice Address - Street 1:1401 S SEWARD MERIDIAN PKWY # ABC
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8312
Practice Address - Country:US
Practice Address - Phone:907-631-3520
Practice Address - Fax:907-631-3634
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant