Provider Demographics
NPI:1114680766
Name:WICKWARE, LORETTA LOUISE
Entity Type:Individual
Prefix:
First Name:LORETTA
Middle Name:LOUISE
Last Name:WICKWARE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:521 S 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85364-2968
Mailing Address - Country:US
Mailing Address - Phone:619-602-7636
Mailing Address - Fax:
Practice Address - Street 1:521 S 7TH AVE
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85364-2968
Practice Address - Country:US
Practice Address - Phone:619-602-7636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider