Healthcare Provider Details

I. General information

NPI: 1366548877
Provider Name (Legal Business Name): MELANIE J KIMMERY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 E BOGARD RD
WASILLA AK
99654-7114
US

IV. Provider business mailing address

1001 E BOGARD RD
WASILLA AK
99654-7114
US

V. Phone/Fax

Practice location:
  • Phone: 907-373-2225
  • Fax: 907-376-9225
Mailing address:
  • Phone: 907-373-2225
  • Fax: 907-376-9225

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberNURU824
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number824
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: