Healthcare Provider Details

I. General information

NPI: 1891919577
Provider Name (Legal Business Name): WICKERSHAM HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 WICKERSHAM WAY
WASILLA AK
99654-7553
US

IV. Provider business mailing address

3950 WICKERSHAM WAY
WASILLA AK
99654-7553
US

V. Phone/Fax

Practice location:
  • Phone: 907-357-8342
  • Fax: 907-357-8342
Mailing address:
  • Phone: 907-357-8342
  • Fax: 907-357-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number100366
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number100366
License Number StateAK

VIII. Authorized Official

Name: MRS. LINDA SHARON HENDRICKSON
Title or Position: ADMINISTRATOR
Credential: CNA, CASP
Phone: 907-357-8342