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General NPI Number Information
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NPI Number | 1407217268
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Entity Type | Individual
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Provider Name | CHRYSTAL MARIE MOON CHA IV
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Gender | Female
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Dates
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Enumeration Date | 03/08/2016
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 100 PUMPHOUSE ROAD
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City | TYONEK
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State | AK
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Zip | 99682
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Country | US
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Telephone | 907-583-2461
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Fax | 907-583-2155
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Provider Business Mailing Address
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Address Line | 7033 E TUDOR RD
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City | ANCHORAGE
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State | AK
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Zip | 99507-1262
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Country | US
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Telephone | 907-729-6799
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Fax | 907-729-5180
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172V00000X
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Taxonomy Name | Community Health Worker
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License Number | 16-1387-IV
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License Number State | AK
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