Provider Demographics
NPI:1033266960
Name:WICKMAN, DANA LYNNE (DC)
Entity Type:Individual
Prefix:DR
First Name:DANA
Middle Name:LYNNE
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:DANA
Other - Middle Name:LYNNE
Other - Last Name:KEANEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:3 YORK RD
Mailing Address - Street 2:
Mailing Address - City:WINDHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03087-2305
Mailing Address - Country:US
Mailing Address - Phone:603-898-0021
Mailing Address - Fax:603-898-9949
Practice Address - Street 1:13 RED ROOF LN
Practice Address - Street 2:SUITE 2-B
Practice Address - City:SALEM
Practice Address - State:NH
Practice Address - Zip Code:03079-2929
Practice Address - Country:US
Practice Address - Phone:603-890-0574
Practice Address - Fax:603-898-9949
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH#588-0200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE6133Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
NHU84413Medicare UPIN