Provider Demographics
NPI:1689706756
Name:WILSON-LAUDUN, GRACE KATHRYN (BSW)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:KATHRYN
Last Name:WILSON-LAUDUN
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6422 E 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99504-1785
Mailing Address - Country:US
Mailing Address - Phone:907-929-8326
Mailing Address - Fax:907-929-8326
Practice Address - Street 1:6422 E 10TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-1785
Practice Address - Country:US
Practice Address - Phone:907-929-8326
Practice Address - Fax:907-929-8326
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKCM95541Medicaid