Provider Demographics
NPI:1992005623
Name:WICKERSHAM, MALISSA D (FNP)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:D
Last Name:WICKERSHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MALISSA
Other - Middle Name:D
Other - Last Name:FLYNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 WAHOO AVE
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-2324
Mailing Address - Country:US
Mailing Address - Phone:860-694-7521
Mailing Address - Fax:
Practice Address - Street 1:1 WAHOO AVE
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349-2324
Practice Address - Country:US
Practice Address - Phone:860-694-7521
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-28
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000606363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily