Provider Demographics
NPI:1013517259
Name:WICKLINE, JENIFFER RACHELLE (APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:JENIFFER
Middle Name:RACHELLE
Last Name:WICKLINE
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1265 MAPLEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:WV
Mailing Address - Zip Code:24901-9478
Mailing Address - Country:US
Mailing Address - Phone:304-645-2700
Mailing Address - Fax:304-645-3188
Practice Address - Street 1:1265 MAPLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:WV
Practice Address - Zip Code:24901-9478
Practice Address - Country:US
Practice Address - Phone:304-645-2700
Practice Address - Fax:304-645-3188
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV106770363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily