Healthcare Provider Details

I. General information

NPI: 1780596288
Provider Name (Legal Business Name): MADISON WICHMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2026
Last Update Date: 09/19/2026
Certification Date: 09/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W SOUTH BOUNDARY ST BLDG 3
PERRYSBURG OH
43551-5230
US

IV. Provider business mailing address

617 HOLGATE AVE
DEFIANCE OH
43512-2037
US

V. Phone/Fax

Practice location:
  • Phone: 419-906-5108
  • Fax:
Mailing address:
  • Phone: 419-906-5108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0043394
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: