Provider Demographics
NPI:1538223391
Name:WICKHAM, JASMINE HILARY (FNP)
Entity type:Individual
Prefix:MS
First Name:JASMINE
Middle Name:HILARY
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:NONE
Other - Middle Name:
Other - Last Name:NONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7755 CENTER AVE
Mailing Address - Street 2:STE 630
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-9152
Mailing Address - Country:US
Mailing Address - Phone:657-400-5180
Mailing Address - Fax:
Practice Address - Street 1:3000 MARCUS AVE STE 2W15
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1005
Practice Address - Country:US
Practice Address - Phone:855-201-4988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334877-1363LF0000X
NYF334877363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty