Provider Demographics
NPI:1730606609
Name:HARRIS-PAULK, ALETHA GAIL
Entity type:Individual
Prefix:
First Name:ALETHA
Middle Name:GAIL
Last Name:HARRIS-PAULK
Suffix:
Gender:F
Credentials:
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 60846
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-6846
Mailing Address - Country:US
Mailing Address - Phone:239-687-9960
Mailing Address - Fax:
Practice Address - Street 1:1940 MARAVILLA AVE
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7135
Practice Address - Country:US
Practice Address - Phone:239-687-9960
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021352600Medicaid