Healthcare Provider Details

I. General information

NPI: 1780052159
Provider Name (Legal Business Name): AMANDA RAE WHOLLY ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 01/09/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

LANDSTUHL REGIONAL MEDICAL CENTER UNIT 33100
APO NY
09180-3100
US

IV. Provider business mailing address

4001 LAKE OTIS PKWY STE 101
ANCHORAGE AK
99508-5200
US

V. Phone/Fax

Practice location:
  • Phone: 153-590-7662
  • Fax:
Mailing address:
  • Phone: 800-769-0045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number103809
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: