Healthcare Provider Details

I. General information

NPI: 1447238860
Provider Name (Legal Business Name): BRENDA RENEE WOLVERTON P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2310 PEGER RD STE 101
FAIRBANKS AK
99709-5315
US

IV. Provider business mailing address

2310 PEGER RD STE 101
FAIRBANKS AK
99709-5315
US

V. Phone/Fax

Practice location:
  • Phone: 907-457-7678
  • Fax: 907-457-7677
Mailing address:
  • Phone: 907-457-7678
  • Fax: 907-457-7677

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number1219
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: