Provider Demographics
NPI:1821440462
Name:WALL-DUNLAP, MCKENNA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:WALL-DUNLAP
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1327 KALAKAKET ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4917
Mailing Address - Country:US
Mailing Address - Phone:907-452-4517
Mailing Address - Fax:907-452-4263
Practice Address - Street 1:1327 KALAKAKET ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4917
Practice Address - Country:US
Practice Address - Phone:907-452-4517
Practice Address - Fax:907-452-4263
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1127652355S0801X
AK185570235Z00000X
AK202508235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant