Provider Demographics
NPI:1790214989
Name:WICKS, XAQUITA (FNP-C, MSN, BSN, RN)
Entity Type:Individual
Prefix:
First Name:XAQUITA
Middle Name:
Last Name:WICKS
Suffix:
Gender:F
Credentials:FNP-C, MSN, BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1759 BROAD PARK CIR S STE 113
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7836
Mailing Address - Country:US
Mailing Address - Phone:817-473-1312
Mailing Address - Fax:
Practice Address - Street 1:2922B MLK JR BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75215-2321
Practice Address - Country:US
Practice Address - Phone:214-708-2739
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-09
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1106498363LF0000X
TX847794163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX847794OtherNURSE LICENSE