Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 176B00000X | Midwife | 524 | AK |
NPI | 1164630042 |
---|---|
Provider Name | Audrey Eileen Small |
First Address | Ketchikan, AK 99901-0033 |
Second Address | Ketchikan, AK 99901-5614 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 21/05/2007 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NM5982 | (05) | AK |
S56670 | (02) | AK |