Provider Demographics
NPI:1295462166
Name:WILMOT, ANJELA KELLI
Entity type:Individual
Prefix:
First Name:ANJELA
Middle Name:KELLI
Last Name:WILMOT
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 1:1535 PORCHET WAY APT C
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-4086
Mailing Address - Country:US
Mailing Address - Phone:907-707-9943
Mailing Address - Fax:
Practice Address - Street 1:1535 PORCHET WAY APT C
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-4086
Practice Address - Country:US
Practice Address - Phone:907-707-9943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7184134171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK7184134Medicaid