Provider Demographics
NPI:1144006511
Name:WICKERD, KATHERINE ANNE
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANNE
Last Name:WICKERD
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 1:503 BENONI AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:FAIRMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26554-3597
Mailing Address - Country:US
Mailing Address - Phone:681-404-2945
Mailing Address - Fax:
Practice Address - Street 1:503 BENONI AVE APT 2
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:WV
Practice Address - Zip Code:26554-3597
Practice Address - Country:US
Practice Address - Phone:681-404-2945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-01
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant