Healthcare Provider Details

I. General information

NPI: 1669060760
Provider Name (Legal Business Name): RESTORE WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3407 WILLOW ST
ANCHORAGE AK
99517-2106
US

IV. Provider business mailing address

PO BOX 91014
ANCHORAGE AK
99509-1014
US

V. Phone/Fax

Practice location:
  • Phone: 907-830-9877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State

VIII. Authorized Official

Name: MS. SUANNE F SIKKEMA
Title or Position: OWNER, NUTRITIONIST
Credential: CNS
Phone: 907-830-9877