Provider Demographics
NPI:1942732474
Name:WICKERSHAM, COLETTE (MA)
Entity Type:Individual
Prefix:MRS
First Name:COLETTE
Middle Name:
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 SAGE ST
Mailing Address - Street 2:
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-2820
Mailing Address - Country:US
Mailing Address - Phone:775-753-2490
Mailing Address - Fax:
Practice Address - Street 1:850 ELM ST
Practice Address - Street 2:
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-3349
Practice Address - Country:US
Practice Address - Phone:775-753-2490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-03
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0000033136174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist