Provider Demographics
NPI:1215649850
Name:WILLARDSON, ANNIE C
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:C
Last Name:WILLARDSON
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 1:5330 N PALMER FISHHOOK RD
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:AK
Mailing Address - Zip Code:99645-8328
Mailing Address - Country:US
Mailing Address - Phone:907-982-1056
Mailing Address - Fax:
Practice Address - Street 1:613 S KNIK GOOSE BAY RD STE D
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8090
Practice Address - Country:US
Practice Address - Phone:907-376-1234
Practice Address - Fax:844-388-8286
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK199288225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty