Provider Demographics
NPI:1326026584
Name:WICKLUND, JUDITH (NP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 159
Mailing Address - Street 2:
Mailing Address - City:ONLEY
Mailing Address - State:VA
Mailing Address - Zip Code:23418-0159
Mailing Address - Country:US
Mailing Address - Phone:757-787-7374
Mailing Address - Fax:757-787-4513
Practice Address - Street 1:20306 BADGER LANE
Practice Address - Street 2:
Practice Address - City:ONLEY
Practice Address - State:VA
Practice Address - Zip Code:23418
Practice Address - Country:US
Practice Address - Phone:757-787-7374
Practice Address - Fax:757-787-4513
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024090481363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q06500Medicare UPIN