MEDICARE: MARIE OLANNA CHA-II

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker	CHA-II	AK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	CHA-II	OTHER	AK	CHA-II

General Provider Information

NPI Number	:	1659758886
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE OLANNA CHA-II

Provider Business Mailing Address
First Line	:	PO BOX 85058
Second Line	:
City	:	BREVIG MISSION
State	:	AK
Zip	:	99785-0058
Country	:	US
Telephone Number	:	907-642-4311
Fax Number	:	907-642-2216

Provider Business Practice Location Address
First Line	:	85058 CLARENCE ROAD
Second Line	:
City	:	BREVIG MISSION
State	:	AK
Zip	:	99785-0058
Country	:	US
Telephone Number	:	907-642-4311
Fax Number	:	907-642-2216

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2015
Last Update Date	:	04/27/2015

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Directions to “ MARIE OLANNA CHA-II” Practice Location

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