Basic Information
| Provider Information | |||||||||
| NPI: | 1538639570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLACKWELL | ||||||||
| FirstName: | WENDY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4191 6TH ST APT 4 | ||||||||
| Address2: | |||||||||
| City: | FORT WAINWRIGHT | ||||||||
| State: | AK | ||||||||
| PostalCode: | 997031249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124015020 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3520 INDUSTRIAL AVE | ||||||||
| Address2: | |||||||||
| City: | FAIRBANKS | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9076875332 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2018 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N |
No ID Information.