Provider Demographics
NPI:1669942694
Name:WICKLIFFE, CARLE DANYELLE
Entity type:Individual
Prefix:
First Name:CARLE
Middle Name:DANYELLE
Last Name:WICKLIFFE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CARLE
Other - Middle Name:DANYELLE
Other - Last Name:WICKLIFFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CARLESHA WOODARD
Mailing Address - Street 1:1360 S ANAHEIM BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6205
Mailing Address - Country:US
Mailing Address - Phone:714-948-7641
Mailing Address - Fax:
Practice Address - Street 1:1360 S ANAHEIM BLVD STE 101
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6205
Practice Address - Country:US
Practice Address - Phone:714-948-7641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator