Provider Demographics
NPI:1891071585
Name:WICKMAN, KENZIE LANE (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:KENZIE
Middle Name:LANE
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5702 RAYMOND RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53711-4232
Mailing Address - Country:US
Mailing Address - Phone:608-278-8037
Mailing Address - Fax:608-278-8213
Practice Address - Street 1:5702 RAYMOND RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53711-4232
Practice Address - Country:US
Practice Address - Phone:608-278-8037
Practice Address - Fax:608-278-8213
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13785-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist