Healthcare Provider Details

I. General information

NPI: 1790214989
Provider Name (Legal Business Name): XAQUITA WICKS FNP-C, MSN, BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2017
Last Update Date: 01/12/2023
Certification Date: 01/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2922B MLK JR BLVD
DALLAS TX
75215-2321
US

IV. Provider business mailing address

1759 BROAD PARK CIR S STE 113
MANSFIELD TX
76063-7836
US

V. Phone/Fax

Practice location:
  • Phone: 214-708-2739
  • Fax:
Mailing address:
  • Phone: 817-473-1312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1106498
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number847794
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: