Provider Demographics
NPI:1730446188
Name:MOLER, KIMBERLY ANN (PDHA II)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:MOLER
Suffix:
Gender:F
Credentials:PDHA II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 605
Mailing Address - Street 2:
Mailing Address - City:KAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99830-0605
Mailing Address - Country:US
Mailing Address - Phone:907-785-6542
Mailing Address - Fax:907-785-3136
Practice Address - Street 1:101 TOTEM WAY
Practice Address - Street 2:
Practice Address - City:KAKE
Practice Address - State:AK
Practice Address - Zip Code:99830
Practice Address - Country:US
Practice Address - Phone:907-785-6542
Practice Address - Fax:907-785-3136
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK09-054-PDHAIIOtherCOMMUNITY HEALTH AIDE PROGRAM CERTIFICATION BOARD - FEDERAL CERTIFICAITON