Provider Demographics
NPI:1912075482
Name:ITANO MERRICK, JOAN C (ANP)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:C
Last Name:ITANO MERRICK
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:C
Other - Last Name:ITANO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:ANP
Mailing Address - Street 1:11472 KENAI SPUR HWY
Mailing Address - Street 2:STE 2
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7756
Mailing Address - Country:US
Mailing Address - Phone:907-283-6030
Mailing Address - Fax:907-283-3194
Practice Address - Street 1:11472 KENAI SPUR HWY
Practice Address - Street 2:STE 2
Practice Address - City:KENAI
Practice Address - State:AK
Practice Address - Zip Code:99611-7756
Practice Address - Country:US
Practice Address - Phone:907-283-6030
Practice Address - Fax:907-283-3194
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK215363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKK160182Medicare ID - Type UnspecifiedMEDICARE
AKS23322Medicare UPIN