Provider Demographics
NPI:1871623538
Name:WICKLIFFE, REBECCA (RNFA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:WICKLIFFE
Suffix:
Gender:F
Credentials:RNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-0371
Mailing Address - Country:US
Mailing Address - Phone:225-654-0310
Mailing Address - Fax:225-654-0310
Practice Address - Street 1:4851 W PARK DR
Practice Address - Street 2:SUITE B
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-4010
Practice Address - Country:US
Practice Address - Phone:225-654-0310
Practice Address - Fax:225-654-0310
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN075524163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant