Provider Demographics
NPI:1558574889
Name:WICK, MONIQUE S
Entity Type:Individual
Prefix:
First Name:MONIQUE
Middle Name:S
Last Name:WICK
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 1:540 W INTERNATIONAL AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-1105
Mailing Address - Country:US
Mailing Address - Phone:907-561-5335
Mailing Address - Fax:907-564-7495
Practice Address - Street 1:9301 GLACIER HWY STE 100
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-9380
Practice Address - Country:US
Practice Address - Phone:907-523-3507
Practice Address - Fax:907-463-3605
Is Sole Proprietor?:No
Enumeration Date:2007-05-07
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKCM4242171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM4242Medicaid