Provider Demographics
NPI:1548907934
Name:LAKE-WICKHAM, MADISON (RN)
Entity type:Individual
Prefix:MS
First Name:MADISON
Middle Name:
Last Name:LAKE-WICKHAM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:MADISON
Other - Middle Name:
Other - Last Name:LACKEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1S210 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:OAKBROOK TERRACE
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1S210 SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:OAKBROOK TERRACE
Practice Address - State:IL
Practice Address - Zip Code:60181-3933
Practice Address - Country:US
Practice Address - Phone:630-282-6004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041519145163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse