Provider Demographics
NPI:1972084580
Name:WICKMAN, TRISHA MELISSA (DNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:TRISHA
Middle Name:MELISSA
Last Name:WICKMAN
Suffix:
Gender:F
Credentials:DNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2648 STATE HIGHWAY M35
Mailing Address - Street 2:
Mailing Address - City:BARK RIVER
Mailing Address - State:MI
Mailing Address - Zip Code:49807-9727
Mailing Address - Country:US
Mailing Address - Phone:906-399-9605
Mailing Address - Fax:
Practice Address - Street 1:2648 STATE HIGHWAY M35
Practice Address - Street 2:
Practice Address - City:BARK RIVER
Practice Address - State:MI
Practice Address - Zip Code:49807-9727
Practice Address - Country:US
Practice Address - Phone:906-399-9605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704210330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704210330OtherAPRN LICENSE