Provider Demographics
NPI:1538783212
Name:WICKARD, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WICKARD
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:PO BOX 366
Mailing Address - Street 2:
Mailing Address - City:CLEARLAKE OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95423-0366
Mailing Address - Country:US
Mailing Address - Phone:707-998-1800
Mailing Address - Fax:
Practice Address - Street 1:14715 EAST HIGHWAY 20
Practice Address - Street 2:
Practice Address - City:CLEARLAKE OAKS
Practice Address - State:CA
Practice Address - Zip Code:95423
Practice Address - Country:US
Practice Address - Phone:707-668-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA271931163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)