Provider Demographics
NPI:1659028090
Name:WICKLIFF, KYLE ALLEN
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:ALLEN
Last Name:WICKLIFF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3850 W WEYBURN RD
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23235-2044
Mailing Address - Country:US
Mailing Address - Phone:540-729-7407
Mailing Address - Fax:
Practice Address - Street 1:3850 W WEYBURN RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23235-2044
Practice Address - Country:US
Practice Address - Phone:540-729-7407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-06
Last Update Date:2022-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001263425163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001263425OtherRN LICENSE