Provider Demographics
NPI:1700339884
Name:WICKSTROM, NANCY E (PTA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:E
Last Name:WICKSTROM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 SKYTOP RD
Mailing Address - Street 2:
Mailing Address - City:IPSWICH
Mailing Address - State:MA
Mailing Address - Zip Code:01938-1476
Mailing Address - Country:US
Mailing Address - Phone:603-502-3746
Mailing Address - Fax:
Practice Address - Street 1:43 SKYTOP RD
Practice Address - Street 2:
Practice Address - City:IPSWICH
Practice Address - State:MA
Practice Address - Zip Code:01938-1476
Practice Address - Country:US
Practice Address - Phone:603-502-3746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-26
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA8412225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant