MEDICARE: REBECCA WICKLIFFE RNFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WR0006X	Registered Nurse First Assistant	RN075524	LA

General Provider Information

NPI Number	:	1871623538
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA WICKLIFFE RNFA

Provider Business Mailing Address
First Line	:	PO BOX 371
Second Line	:
City	:	ZACHARY
State	:	LA
Zip	:	70791-0371
Country	:	US
Telephone Number	:	225-654-0310
Fax Number	:	225-654-0310

Provider Business Practice Location Address
First Line	:	4851 W PARK DR
Second Line	:	SUITE B
City	:	ZACHARY
State	:	LA
Zip	:	70791-4010
Country	:	US
Telephone Number	:	225-654-0310
Fax Number	:	225-654-0310

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2007
Last Update Date	:	07/08/2007

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