Provider Demographics
NPI:1679941454
Name:WICKLINE, LISA (RN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WICKLINE
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 1:2393 W ALLYN RD
Mailing Address - Street 2:
Mailing Address - City:MERCER
Mailing Address - State:WI
Mailing Address - Zip Code:54547-9402
Mailing Address - Country:US
Mailing Address - Phone:715-892-6551
Mailing Address - Fax:
Practice Address - Street 1:2393 W ALLYN RD
Practice Address - Street 2:
Practice Address - City:MERCER
Practice Address - State:WI
Practice Address - Zip Code:54547-9402
Practice Address - Country:US
Practice Address - Phone:715-892-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI98101163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse