Healthcare Provider Details

I. General information

NPI: 1477743755
Provider Name (Legal Business Name): EDGAR NOLLNER HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2007
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 ANTOSKI
GALENA AK
99741-0077
US

IV. Provider business mailing address

PO BOX 77
GALENA AK
99741-0077
US

V. Phone/Fax

Practice location:
  • Phone: 907-656-2366
  • Fax: 907-656-3122
Mailing address:
  • Phone: 907-656-2366
  • Fax: 907-656-3122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code261QR1100X
TaxonomyResearch Clinic/Center
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: MS. KIM L. WOLF
Title or Position: FINANCE MANAGER
Credential:
Phone: 907-656-2489