Provider Demographics
NPI:1376985374
Name:WICKMAN, KIM (RN)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3037 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49445-2123
Mailing Address - Country:US
Mailing Address - Phone:231-755-0637
Mailing Address - Fax:231-744-6208
Practice Address - Street 1:955 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-3521
Practice Address - Country:US
Practice Address - Phone:231-755-0637
Practice Address - Fax:231-755-6208
Is Sole Proprietor?:No
Enumeration Date:2013-07-19
Last Update Date:2013-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704183701163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse