Provider Demographics
NPI:1760994404
Name:WICKENHAUSER, SARAH RAE
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:RAE
Last Name:WICKENHAUSER
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 1:2806 E ANDREW RD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN
Mailing Address - State:IL
Mailing Address - Zip Code:62684-9517
Mailing Address - Country:US
Mailing Address - Phone:217-483-1900
Mailing Address - Fax:
Practice Address - Street 1:5220 6TH STREET FRONTAGE RD E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-5735
Practice Address - Country:US
Practice Address - Phone:217-993-0998
Practice Address - Fax:217-529-4228
Is Sole Proprietor?:No
Enumeration Date:2017-11-03
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016863363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner