Provider Demographics
NPI:1558896175
Name:WICKENHAGEN, ALYSSA NOELLE (ATC)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:NOELLE
Last Name:WICKENHAGEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 N 91ST AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-8473
Mailing Address - Country:US
Mailing Address - Phone:509-961-5124
Mailing Address - Fax:
Practice Address - Street 1:106 N 91ST AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908
Practice Address - Country:US
Practice Address - Phone:509-961-5124
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer