Provider Demographics
NPI:1487386462
Name:MUNTHALI, WEZZIE DAMALIS
Entity type:Individual
Prefix:
First Name:WEZZIE
Middle Name:DAMALIS
Last Name:MUNTHALI
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 1:3614 W 40TH AVE APT B
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99517-2701
Mailing Address - Country:US
Mailing Address - Phone:907-538-7712
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE OTIS PKWY STE 322
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5231
Practice Address - Country:US
Practice Address - Phone:907-562-1234
Practice Address - Fax:907-677-2007
Is Sole Proprietor?:No
Enumeration Date:2022-06-28
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK192639363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner