Provider Demographics
NPI:1033875240
Name:WICKS, KAYLA (CPO, LPO)
Entity Type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:WICKS
Suffix:
Gender:F
Credentials:CPO, LPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 GISH RD
Mailing Address - Street 2:
Mailing Address - City:ONALASKA
Mailing Address - State:WA
Mailing Address - Zip Code:98570-9529
Mailing Address - Country:US
Mailing Address - Phone:253-797-5163
Mailing Address - Fax:
Practice Address - Street 1:1516 HUDSON ST STE 105
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-3046
Practice Address - Country:US
Practice Address - Phone:360-423-6049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPS61132736224P00000X
WAOI61230221222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist