Provider Demographics
NPI:1851723555
Name:WICKWIRE, ADRIENNE L (DPT)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:L
Last Name:WICKWIRE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:L
Other - Last Name:BEAUDUY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 CRYSTAL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-1966
Mailing Address - Country:US
Mailing Address - Phone:717-554-6140
Mailing Address - Fax:
Practice Address - Street 1:2250 MILLENNIUM WAY
Practice Address - Street 2:SUITE 400
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1488
Practice Address - Country:US
Practice Address - Phone:717-732-8131
Practice Address - Fax:717-732-8132
Is Sole Proprietor?:No
Enumeration Date:2013-08-05
Last Update Date:2022-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT022809225100000X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA332106R9XMedicare Oscar/Certification