Healthcare Provider Details

I. General information

NPI: 1053883595
Provider Name (Legal Business Name): MOOSE CREEK MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2341 S. FERN ST., SUITE 300
WASILLA AK
99654
US

IV. Provider business mailing address

2341 S. FERN ST., SUITE 300
WASILLA AK
99654
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-3335
  • Fax: 907-373-3331
Mailing address:
  • Phone: 907-373-3335
  • Fax: 907-373-3331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MRS. KIMBERLI RAYE BROCK
Title or Position: ADVANCED NURSE PRACTITIONER, BUSINE
Credential: ANP
Phone: 907-373-3335