Provider Demographics
NPI:1124371349
Name:WASSILLIE, AMY J
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:J
Last Name:WASSILLIE
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:P.O. BOX 130
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:DILLINGHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99576-0130
Mailing Address - Country:US
Mailing Address - Phone:907-842-9217
Mailing Address - Fax:907-842-9250
Practice Address - Street 1:6000 KANAKANAK RD
Practice Address - Street 2:MEDICAL STAFF DEPARTMENT
Practice Address - City:DILLINGHAM
Practice Address - State:AK
Practice Address - Zip Code:99576-0130
Practice Address - Country:US
Practice Address - Phone:907-842-9217
Practice Address - Fax:907-842-9250
Is Sole Proprietor?:No
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK07-935-P172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker