Provider Demographics
NPI:1073192977
Name:WHITTENBERG, MADISON
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:WHITTENBERG
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 1:1365 E PRKS HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-357-6445
Mailing Address - Fax:
Practice Address - Street 1:1365 E PRKS HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654
Practice Address - Country:US
Practice Address - Phone:907-357-6445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker