Provider Demographics
NPI:1750945317
Name:STURDEVANT, RELL D
Entity type:Individual
Prefix:
First Name:RELL
Middle Name:D
Last Name:STURDEVANT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11267 W BIG DIPPER DR
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99623-4914
Mailing Address - Country:US
Mailing Address - Phone:907-841-7144
Mailing Address - Fax:
Practice Address - Street 1:11267 W BIG DIPPER DR
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-4914
Practice Address - Country:US
Practice Address - Phone:907-841-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program