Provider Demographics
NPI:1215072905
Name:WICK, SHERRY K (MSN, CPNP)
Entity type:Individual
Prefix:MS
First Name:SHERRY
Middle Name:K
Last Name:WICK
Suffix:
Gender:F
Credentials:MSN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31713 TRADEWINDS DR
Mailing Address - Street 2:
Mailing Address - City:AVON LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44012-2915
Mailing Address - Country:US
Mailing Address - Phone:440-835-5833
Mailing Address - Fax:
Practice Address - Street 1:14701 DETROIT AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-4115
Practice Address - Country:US
Practice Address - Phone:216-221-5901
Practice Address - Fax:216-221-5881
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2011-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-148453363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0196272Medicaid