Healthcare Provider Details

I. General information

NPI: 1609298421
Provider Name (Legal Business Name): MICHAEL SMALLEY LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2014
Last Update Date: 01/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1296 AGVIK STREET
BARROW AK
99723-0029
US

IV. Provider business mailing address

PO BOX 29
BARROW AK
99723-0029
US

V. Phone/Fax

Practice location:
  • Phone: 907-852-9203
  • Fax: 907-852-6616
Mailing address:
  • Phone: 907-852-9203
  • Fax: 907-852-6616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number6696
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: