Provider Demographics
NPI:1750704516
Name:MAVAEGA, ENI IERUSALEMA
Entity type:Individual
Prefix:MISS
First Name:ENI
Middle Name:IERUSALEMA
Last Name:MAVAEGA
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 1:4040 WORONZOF DR.
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-2242
Mailing Address - Country:US
Mailing Address - Phone:907-297-8942
Mailing Address - Fax:907-222-5950
Practice Address - Street 1:343 W BENSON BLVD STE 4
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-3950
Practice Address - Country:US
Practice Address - Phone:907-222-3237
Practice Address - Fax:907-222-5950
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator