Healthcare Provider Details

I. General information

NPI: 1699209825
Provider Name (Legal Business Name): CHELSEA ELIZABETH WICKENHEISER D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/13/2017
Last Update Date: 07/22/2020
Certification Date: 07/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2909 E GRAND RIVER AVE STE 302
LANSING MI
48912-4335
US

IV. Provider business mailing address

909 E CESAR E CHAVEZ AVE # 302
LANSING MI
48906-5345
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-8680
  • Fax:
Mailing address:
  • Phone: 517-365-8680
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5151013267
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: