Healthcare Provider Details

I. General information

NPI: 1649206269
Provider Name (Legal Business Name): DENISE ANN WIKSTEN PHD, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 CAMPANILE DR DEPT. OF EXERCISE & NUTRITIONAL SCIENCES
SAN DIEGO CA
92182-0001
US

IV. Provider business mailing address

5500 CAMPANILE DR DEPT. OF EXERCISE & NUTRITIONAL SCIENCES
SAN DIEGO CA
92182-0001
US

V. Phone/Fax

Practice location:
  • Phone: 619-594-6825
  • Fax: 619-594-6623
Mailing address:
  • Phone: 619-594-6825
  • Fax: 619-594-6623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: