Healthcare Provider Details

I. General information

NPI: 1629813704
Provider Name (Legal Business Name): KATHERINE MARIE WICKSTROM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHERINE MARIE LEDDY

II. Dates (important events)

Enumeration Date: 06/28/2024
Last Update Date: 06/28/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 HELMO AVE N STE 100
OAKDALE MN
55128-6034
US

IV. Provider business mailing address

2828 HIGHWAY 88
ST ANTHONY MN
55418-3243
US

V. Phone/Fax

Practice location:
  • Phone: 651-326-5300
  • Fax:
Mailing address:
  • Phone: 605-254-3402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06242189
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: