Provider Demographics
NPI:1174204200
Name:BALLARD, TAWANDA BETTY
Entity type:Individual
Prefix:
First Name:TAWANDA
Middle Name:BETTY
Last Name:BALLARD
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 70612
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99707-0612
Mailing Address - Country:US
Mailing Address - Phone:570-604-3984
Mailing Address - Fax:
Practice Address - Street 1:1825 MARIKA RD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-5521
Practice Address - Country:US
Practice Address - Phone:570-604-3984
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker