Healthcare Provider Details

I. General information

NPI: 1720817018
Provider Name (Legal Business Name): VANESSA MICHELLE WICKHAM NP, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS VANESSA MICHELLE JOHNSTON

II. Dates (important events)

Enumeration Date: 07/26/2024
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 GENESEE AVE STE 560
LA JOLLA CA
92037-1229
US

IV. Provider business mailing address

5241 JAMESTOWN RD
SAN DIEGO CA
92117-1244
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-1410
  • Fax:
Mailing address:
  • Phone: 714-824-7838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP95030225
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: