Provider Demographics
NPI:1720225550
Name:KILANOWSKI, SANDRA E
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:E
Last Name:KILANOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:
Other - Last Name:SPIEGELBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5900 W LOCKSLEY LOOP
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-357-7477
Mailing Address - Fax:
Practice Address - Street 1:7362 W PARKS HWY # 204
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-9132
Practice Address - Country:US
Practice Address - Phone:907-357-7478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK741871305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1851518815Medicaid