Provider Demographics
NPI:1912345570
Name:SIMON, MINNIE CHERYL JOLENE
Entity Type:Individual
Prefix:
First Name:MINNIE
Middle Name:CHERYL JOLENE
Last Name:SIMON
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:PO BOX 49
Mailing Address - Street 2:
Mailing Address - City:HOOPER BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99604-0049
Mailing Address - Country:US
Mailing Address - Phone:907-758-3500
Mailing Address - Fax:907-758-3540
Practice Address - Street 1:829 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:SUITE 150
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6100
Practice Address - Fax:907-543-6159
Is Sole Proprietor?:No
Enumeration Date:2013-06-05
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid