Provider Demographics
NPI:1679797435
Name:WILD, LINDA CAROLE (RD)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:CAROLE
Last Name:WILD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 20704
Mailing Address - Street 2:
Mailing Address - City:JUNEAU
Mailing Address - State:AK
Mailing Address - Zip Code:99802-0704
Mailing Address - Country:US
Mailing Address - Phone:907-723-3932
Mailing Address - Fax:907-796-8673
Practice Address - Street 1:3260 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7808
Practice Address - Country:US
Practice Address - Phone:907-796-8691
Practice Address - Fax:906-796-8673
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK17133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered