Provider Demographics
NPI:1205090586
Name:WICKLINE, LAURA MARIE (PMHNP)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:WICKLINE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:DEUTSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1132 SW 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97205-1703
Mailing Address - Country:US
Mailing Address - Phone:503-484-3341
Mailing Address - Fax:
Practice Address - Street 1:1132 SW 13TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1703
Practice Address - Country:US
Practice Address - Phone:503-484-3341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200442418RN163WP0808X
OR200950021NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health