Healthcare Provider Details

I. General information

NPI: 1538856984
Provider Name (Legal Business Name): KANISHA LANAE TIEDEMAN DOULA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 MILE HARTNEY BAY ROAD
CORDOVA AK
99574-1275
US

IV. Provider business mailing address

PO BOX 1275
CORDOVA AK
99574-1275
US

V. Phone/Fax

Practice location:
  • Phone: 907-235-9642
  • Fax:
Mailing address:
  • Phone: 907-235-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: