Provider Demographics
NPI:1861262842
Name:MARTIN, SUSIE ALMA
Entity type:Individual
Prefix:
First Name:SUSIE
Middle Name:ALMA
Last Name:MARTIN
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 6059
Mailing Address - Street 2:
Mailing Address - City:MENTASTA LAKE
Mailing Address - State:AK
Mailing Address - Zip Code:99780-6059
Mailing Address - Country:US
Mailing Address - Phone:907-291-2320
Mailing Address - Fax:
Practice Address - Street 1:MILE 111.5 RICHARDSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:GLENNALLEN
Practice Address - State:AK
Practice Address - Zip Code:99588
Practice Address - Country:US
Practice Address - Phone:907-822-5241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK23-1724-I172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker