Provider Demographics
NPI:1437770625
Name:WICKLUND, SHANA ROSE
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:ROSE
Last Name:WICKLUND
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 1:25 BROOKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NORTH SCITUATE
Mailing Address - State:RI
Mailing Address - Zip Code:02857-1576
Mailing Address - Country:US
Mailing Address - Phone:401-787-4684
Mailing Address - Fax:
Practice Address - Street 1:1672 S COUNTY TRL STE 302
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-5099
Practice Address - Country:US
Practice Address - Phone:401-336-3770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant