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General NPI Number Information
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NPI Number | 1053883595
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Entity Type | Organization
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Legal Business Name | MOOSE CREEK MEDICAL CLINIC LLC
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Dates
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Enumeration Date | 12/21/2018
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Last Update Date | 12/21/2018
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Provider Practice Location Address
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Address Line | 2341 S. FERN ST., SUITE 300
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City | WASILLA
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State | AK
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Zip | 99654
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Country | US
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Telephone | 907-373-3335
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Fax | 907-373-3331
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Provider Business Mailing Address
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Address Line | 2341 S. FERN ST., SUITE 300
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City | WASILLA
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State | AK
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Zip | 99654
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Country | US
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Telephone | 907-373-3335
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Fax | 907-373-3331
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Authorized Official
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Title or Position | ADVANCED NURSE PRACTITIONER, BUSINE
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Name | MRS. KIMBERLI RAYE BROCK
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Credential | ANP
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Telephone | 907-373-3335
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number |
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License Number State |
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