Healthcare Provider Details

I. General information

NPI: 1114163433
Provider Name (Legal Business Name): LAURA K WICK RN, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 12/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 JUNCTION RD
MADISON WI
53717-2656
US

IV. Provider business mailing address

451 JUNCTION RD
MADISON WI
53717-2656
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-7741
  • Fax: 608-265-7519
Mailing address:
  • Phone: 608-263-7741
  • Fax: 608-265-7519

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number112534-030
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: