Provider Demographics
NPI:1265478622
Name:WICKMAN, CRISTY H (CFNP)
Entity Type:Individual
Prefix:MS
First Name:CRISTY
Middle Name:H
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:901 W ALAMEDA ST
Mailing Address - Street 2:SUITE 25
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1673
Mailing Address - Country:US
Mailing Address - Phone:505-988-8869
Mailing Address - Fax:505-982-7321
Practice Address - Street 1:901 W ALAMEDA ST
Practice Address - Street 2:SUITE 25
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1673
Practice Address - Country:US
Practice Address - Phone:505-988-8869
Practice Address - Fax:505-982-6298
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMNM48727363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMP86557Medicare UPIN