Provider Demographics
NPI:1346627163
Name:WICKER, STEPHANIE (NP-C)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WICKER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 ARBOR GATE CT
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-3600
Mailing Address - Country:US
Mailing Address - Phone:317-694-0571
Mailing Address - Fax:
Practice Address - Street 1:1402 E COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-0963
Practice Address - Country:US
Practice Address - Phone:317-355-5486
Practice Address - Fax:317-351-3488
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005448A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201290950Medicaid
INP02198230OtherMEDICARE RR