Provider Demographics
NPI:1033397765
Name:WICKHAM, GERALDINE MARGARET (LPN)
Entity Type:Individual
Prefix:MS
First Name:GERALDINE
Middle Name:MARGARET
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7377 COMMON RD
Mailing Address - Street 2:
Mailing Address - City:ANGELICA
Mailing Address - State:NY
Mailing Address - Zip Code:14709-8712
Mailing Address - Country:US
Mailing Address - Phone:585-957-5343
Mailing Address - Fax:
Practice Address - Street 1:7377 COMMON RD
Practice Address - Street 2:
Practice Address - City:ANGELICA
Practice Address - State:NY
Practice Address - Zip Code:14709-8712
Practice Address - Country:US
Practice Address - Phone:585-957-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267652-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02427241Medicaid