Provider Demographics
NPI:1710698667
Name:WICKFORD FAMILY PRACTICE LLC
Entity Type:Organization
Organization Name:WICKFORD FAMILY PRACTICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAXWELL
Authorized Official - Middle Name:
Authorized Official - Last Name:HOGUE
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:603-667-6765
Mailing Address - Street 1:619 BOSTON NECK RD
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-6235
Mailing Address - Country:US
Mailing Address - Phone:603-667-6765
Mailing Address - Fax:
Practice Address - Street 1:320 PHILLIPS ST STE 102
Practice Address - Street 2:
Practice Address - City:NORTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02852-5149
Practice Address - Country:US
Practice Address - Phone:603-667-6765
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-12-12
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1235789231Medicaid
RIAPRN02399OtherSTATE NP LICENSE