Healthcare Provider Details

I. General information

NPI: 1225218746
Provider Name (Legal Business Name): DEBORAH LYNN WICKENDEN RN,NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 4TH ST
MISHAWAKA IN
46544-1948
US

IV. Provider business mailing address

2401 VALLEY DR
VALPARAISO IN
46383-2520
US

V. Phone/Fax

Practice location:
  • Phone: 574-307-7673
  • Fax: 574-307-7692
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71002529A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: