Provider Demographics
NPI:1366816431
Name:WICKHAM, KELSY
Entity Type:Individual
Prefix:
First Name:KELSY
Middle Name:
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 1:6030 HUNTERS RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-7919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6030 HUNTERS RIDGE DR
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IN
Practice Address - Zip Code:46168-7919
Practice Address - Country:US
Practice Address - Phone:317-603-3244
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-30
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer