Provider Demographics
NPI:1336382118
Name:WICKERHAM, HALEY DANIELLE (LPN)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:DANIELLE
Last Name:WICKERHAM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 ROCK CREEK DR
Mailing Address - Street 2:
Mailing Address - City:GROVE CITY
Mailing Address - State:OH
Mailing Address - Zip Code:43123-1542
Mailing Address - Country:US
Mailing Address - Phone:614-937-8430
Mailing Address - Fax:
Practice Address - Street 1:1716 ROCK CREEK DR
Practice Address - Street 2:
Practice Address - City:GROVE CITY
Practice Address - State:OH
Practice Address - Zip Code:43123-1542
Practice Address - Country:US
Practice Address - Phone:614-937-8430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-09
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN134031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse