Provider Demographics
NPI:1194687251
Name:EGBERT, SERENA
Entity type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:EGBERT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 N MAIN ST UNIT 875756
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99687-1797
Mailing Address - Country:US
Mailing Address - Phone:907-203-6793
Mailing Address - Fax:907-313-3879
Practice Address - Street 1:10927 W BIG LAKE RD STE C
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-3301
Practice Address - Country:US
Practice Address - Phone:907-203-6793
Practice Address - Fax:907-313-3879
Is Sole Proprietor?:No
Enumeration Date:2025-11-26
Last Update Date:2025-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK244536225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist