Provider Demographics
NPI:1346042025
Name:MUDRICK, MIKALA RAIN
Entity type:Individual
Prefix:
First Name:MIKALA
Middle Name:RAIN
Last Name:MUDRICK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 CYPRESS DR
Mailing Address - Street 2:
Mailing Address - City:KENAI
Mailing Address - State:AK
Mailing Address - Zip Code:99611-7519
Mailing Address - Country:US
Mailing Address - Phone:208-413-4262
Mailing Address - Fax:
Practice Address - Street 1:33870 POLAR ST
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-9251
Practice Address - Country:US
Practice Address - Phone:907-260-4844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-25
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK234247225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist