Healthcare Provider Details

I. General information

NPI: 1629261029
Provider Name (Legal Business Name): WENDY CHANTEL MOREIKO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: WENDY CHANTEL REITHER PTA

II. Dates (important events)

Enumeration Date: 08/20/2007
Last Update Date: 08/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 W BONDELL ST
WASILLA AK
99654
US

IV. Provider business mailing address

PO BOX 298658
WASILLA AK
99629
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-9755
  • Fax:
Mailing address:
  • Phone: 907-357-9755
  • Fax: 907-357-9499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number305
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: