Healthcare Provider Details

I. General information

NPI: 1508689092
Provider Name (Legal Business Name): SHYANNE MANDY KOPANUK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 11/04/2024
Certification Date: 11/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1825 MARIKA RD
FAIRBANKS AK
99709-5521
US

IV. Provider business mailing address

1825 MARIKA RD
FAIRBANKS AK
99709-5521
US

V. Phone/Fax

Practice location:
  • Phone: 907-474-0890
  • Fax: 907-474-3261
Mailing address:
  • Phone: 907-474-0890
  • Fax: 907-474-3261

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: