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General NPI Number Information
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NPI Number | 1235105230
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Entity Type | Individual
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Provider Name | LOELLA E. CLARK WICKEY MD
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Gender | Female
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Dates
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Enumeration Date | 02/28/2006
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Last Update Date | 11/02/2007
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Provider Practice Location Address
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Address Line | 130 CENTER WAY
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City | CORNING
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State | NY
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Zip | 14830-2255
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Country | US
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Telephone | 607-936-9971
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Fax | 607-936-2600
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Provider Business Mailing Address
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Address Line | 1 GUTHRIE SQ
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City | SAYRE
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State | PA
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Zip | 18840-1625
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Country | US
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Telephone | 570-888-5858
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Fax | 570-882-3007
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 173504-1
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License Number State | NY
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