Provider Demographics
NPI:1386835213
Name:DIMMICK, SHERRY
Entity Type:Individual
Prefix:
First Name:SHERRY
Middle Name:
Last Name:DIMMICK
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 1:357 E PARKS HWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7040
Mailing Address - Country:US
Mailing Address - Phone:907-357-5627
Mailing Address - Fax:907-357-5628
Practice Address - Street 1:600 BARROW ST
Practice Address - Street 2:SUITE 404
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-3631
Practice Address - Country:US
Practice Address - Phone:907-258-3498
Practice Address - Fax:907-279-0171
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK272340171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM1654Medicaid