Provider Demographics
NPI:1164069431
Name:WICHMANN, MARY ANN
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:WICHMANN
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 1:20338 COUNTY HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:ROCHERT
Mailing Address - State:MN
Mailing Address - Zip Code:56578-9608
Mailing Address - Country:US
Mailing Address - Phone:218-849-1091
Mailing Address - Fax:
Practice Address - Street 1:20338 COUNTY HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:ROCHERT
Practice Address - State:MN
Practice Address - Zip Code:56578-9608
Practice Address - Country:US
Practice Address - Phone:218-849-1091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-05
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer