Healthcare Provider Details

I. General information

NPI: 1255996351
Provider Name (Legal Business Name): SHELLY LYNN NIBLACK CDC L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 05/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10200 KENAI SOUR HWY
KENAI AK
99611
US

IV. Provider business mailing address

PO BOX 882
KENAI AK
99611-0882
US

V. Phone/Fax

Practice location:
  • Phone: 907-283-3658
  • Fax:
Mailing address:
  • Phone: 907-283-3658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: