MEDICARE: AUDREY EILEEN SMALL CNM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	176B00000X	Midwife	524	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164630042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDREY EILEEN SMALL CNM

Provider Business Mailing Address
First Line	:	PO BOX 5098
Second Line	:
City	:	KETCHIKAN
State	:	AK
Zip	:	99901-0033
Country	:	US
Telephone Number	:	907-225-1231
Fax Number	:	907-247-1231

Provider Business Practice Location Address
First Line	:	355 CARLANNA LAKE RD LOWR
Second Line	:
City	:	KETCHIKAN
State	:	AK
Zip	:	99901-5614
Country	:	US
Telephone Number	:	907-225-1231
Fax Number	:	907-247-1231

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2007
Last Update Date	:	07/09/2007

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