Provider Demographics
NPI:1629790449
Name:WICKHAM, SANDRA
Entity Type:Individual
Prefix:
First Name:SANDRA
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 1:30852 MIDTOWN CT
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-1333
Mailing Address - Country:US
Mailing Address - Phone:315-804-0103
Mailing Address - Fax:
Practice Address - Street 1:30852 MIDTOWN CT
Practice Address - Street 2:
Practice Address - City:WESLEY CHAPEL
Practice Address - State:FL
Practice Address - Zip Code:33545-1333
Practice Address - Country:US
Practice Address - Phone:352-410-9061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-19
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide