Provider Demographics
NPI:1093238040
Name:WICHMAN, CAROLINE M (NP)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:M
Last Name:WICHMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 RIVER RD STE 2-03
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-1938
Mailing Address - Country:US
Mailing Address - Phone:201-692-2437
Mailing Address - Fax:201-692-2214
Practice Address - Street 1:1000 RIVER RD STE 2-03
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-1938
Practice Address - Country:US
Practice Address - Phone:201-692-2437
Practice Address - Fax:201-692-2214
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024175118363LF0000X
NJ26NJ01214900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06778OtherMEDICARE PTAN