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General NPI Number Information
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NPI Number | 1396124897
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Entity Type | Organization
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Legal Business Name | KIMBERLY J WONDERLICH MD FAAD DERMATOLOGY LLC
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Dates
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Enumeration Date | 05/29/2015
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Last Update Date | 02/13/2019
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Provider Practice Location Address
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Address Line | 2775 COLLEGE ROAD
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City | FAIRBANKS
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State | AK
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Zip | 99709
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Country | US
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Telephone | 907-456-1979
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Fax |
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Provider Business Mailing Address
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Address Line | 2775 COLLEGE RD
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City | FAIRBANKS
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State | AK
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Zip | 99709-3751
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Country | US
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Telephone | 907-456-1979
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Fax | 907-456-1903
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | KIMBERLY WONDERLICH
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Credential |
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Telephone | 907-456-1979
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207N00000X
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Taxonomy Name | Dermatology Physician
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License Number | 8102
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License Number State | AK
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