Provider Demographics
NPI:1669405197
Name:WICKSTROM, BETTY R (NP)
Entity type:Individual
Prefix:
First Name:BETTY
Middle Name:R
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:960 JOHNSON FERRY RD NE
Mailing Address - Street 2:SUITE 336
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1631
Mailing Address - Country:US
Mailing Address - Phone:404-252-7400
Mailing Address - Fax:404-252-1772
Practice Address - Street 1:960 JOHNSON FERRY RD NE
Practice Address - Street 2:SUITE 336
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1631
Practice Address - Country:US
Practice Address - Phone:404-252-7400
Practice Address - Fax:404-252-1772
Is Sole Proprietor?:No
Enumeration Date:2006-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN045532363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health