Provider Demographics
NPI:1114981842
Name:WICKER, LAURA JEAN (FNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:WICKER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:3554 PROMENADE PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47909-8418
Mailing Address - Country:US
Mailing Address - Phone:574-992-1226
Mailing Address - Fax:765-230-2901
Practice Address - Street 1:3554 PROMENADE PKWY STE B
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47909-8418
Practice Address - Country:US
Practice Address - Phone:574-946-2194
Practice Address - Fax:574-946-2196
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001702A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN941280Medicare PIN
INQ21026Medicare UPIN
IN231400JMedicare ID - Type UnspecifiedRENDERING # - MEMORIAL