Provider Demographics
NPI:1386433423
Name:WALLINGFORD, JOHN RALPH JR
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:RALPH
Last Name:WALLINGFORD
Suffix:JR
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 1:591 S KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-8062
Mailing Address - Country:US
Mailing Address - Phone:907-313-1333
Mailing Address - Fax:
Practice Address - Street 1:1419 S KITTIWAKE ST
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99623-9302
Practice Address - Country:US
Practice Address - Phone:907-313-1333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-05
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist