Healthcare Provider Details

I. General information

NPI: 1871623538
Provider Name (Legal Business Name): REBECCA WICKLIFFE RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4851 W PARK DR SUITE B
ZACHARY LA
70791-4010
US

IV. Provider business mailing address

PO BOX 371
ZACHARY LA
70791-0371
US

V. Phone/Fax

Practice location:
  • Phone: 225-654-0310
  • Fax: 225-654-0310
Mailing address:
  • Phone: 225-654-0310
  • Fax: 225-654-0310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberRN075524
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: