Provider Demographics
NPI:1821285446
Name:WICKLIFFE, DEBRA
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WICKLIFFE
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 1:134 NW OLIVE GLN
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-9210
Mailing Address - Country:US
Mailing Address - Phone:386-965-2770
Mailing Address - Fax:386-965-2770
Practice Address - Street 1:134 NW OLIVE GLN
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-9210
Practice Address - Country:US
Practice Address - Phone:386-965-2770
Practice Address - Fax:386-754-2770
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-27
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6908802996171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6908802965Medicaid