Provider Demographics
NPI:1336293851
Name:WICKHAM, ELLA MAE
Entity Type:Individual
Prefix:MRS
First Name:ELLA
Middle Name:MAE
Last Name:WICKHAM
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 1:117 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-2803
Mailing Address - Country:US
Mailing Address - Phone:276-632-3198
Mailing Address - Fax:276-632-3199
Practice Address - Street 1:117 BROAD ST
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-2803
Practice Address - Country:US
Practice Address - Phone:276-632-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA1201044757174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist