Provider Demographics
NPI:1164799649
Name:WICKWIRE, ASHLEY SHAVON (LMT)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:SHAVON
Last Name:WICKWIRE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:MS
Other - First Name:ASHLEY
Other - Middle Name:SHAVON
Other - Last Name:MCCARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10905 CLAREMONT AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1606
Mailing Address - Country:US
Mailing Address - Phone:505-712-0122
Mailing Address - Fax:
Practice Address - Street 1:10905 CLAREMONT AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1606
Practice Address - Country:US
Practice Address - Phone:505-712-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-28
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM7130171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor