Provider Demographics
NPI:1114937661
Name:WICKENKAMP, CAROLYN KAY (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:KAY
Last Name:WICKENKAMP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15425 E MISSION AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-9505
Mailing Address - Country:US
Mailing Address - Phone:509-924-7010
Mailing Address - Fax:509-924-7532
Practice Address - Street 1:8795 W DRIFTWOOD DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-9602
Practice Address - Country:US
Practice Address - Phone:208-777-8427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034130207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A51733Medicare UPIN