Provider Demographics
NPI:1629813704
Name:WICKSTROM, KATHERINE MARIE (CNP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:MARIE
Other - Last Name:LEDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2828 HIGHWAY 88
Mailing Address - Street 2:
Mailing Address - City:ST ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418-3243
Mailing Address - Country:US
Mailing Address - Phone:605-254-3402
Mailing Address - Fax:
Practice Address - Street 1:1099 HELMO AVE N STE 100
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-6034
Practice Address - Country:US
Practice Address - Phone:651-326-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNF06242189363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily