Healthcare Provider Details

I. General information

NPI: 1922295773
Provider Name (Legal Business Name): IRENE BULAONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 ADONIS DR
ANCHORAGE AK
99515-4511
US

IV. Provider business mailing address

11615 FRANCES ELAINE CIR
ANCHORAGE AK
99515-3396
US

V. Phone/Fax

Practice location:
  • Phone: 907-350-3606
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376G00000X
TaxonomyNursing Home Administrator
License Number741060
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: