Provider Demographics
NPI:1346211505
Name:WONDERLICH, KIMBERLY JANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:JANNE
Last Name:WONDERLICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 COLLEGE ROAD
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-456-1979
Mailing Address - Fax:
Practice Address - Street 1:2775 COLLEGE ROAD
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-456-1979
Practice Address - Fax:907-456-1903
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE23558207N00000X
AK8102207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology