Provider Demographics
NPI:1760779409
Name:MCLAMB, JESSICA WIKSTROM (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:WIKSTROM
Last Name:MCLAMB
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ROSE
Other - Last Name:WIKSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:295 NEELY RD
Mailing Address - Street 2:
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712-4199
Mailing Address - Country:US
Mailing Address - Phone:828-713-6793
Mailing Address - Fax:
Practice Address - Street 1:295 NEELY RD
Practice Address - Street 2:
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712-4199
Practice Address - Country:US
Practice Address - Phone:828-713-6793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC210079367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ44938AMedicare PIN