Provider Demographics
NPI:1932838273
Name:WICKREMA, TARYN KELLY
Entity Type:Individual
Prefix:
First Name:TARYN
Middle Name:KELLY
Last Name:WICKREMA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 3RD ST S
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22204-1662
Mailing Address - Country:US
Mailing Address - Phone:717-919-6614
Mailing Address - Fax:
Practice Address - Street 1:3618 3RD ST S
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22204-1662
Practice Address - Country:US
Practice Address - Phone:717-919-6614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-09
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1047316163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine