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General NPI Number Information
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NPI Number | 1386081115
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Entity Type | Individual
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Provider Name | ELLICE ANN WICKWIRE R.N.
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Gender | Female
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Dates
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Enumeration Date | 06/03/2013
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Last Update Date | 06/03/2013
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Provider Practice Location Address
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Address Line | 907 S MAIN ST
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City | PINCKNEYVILLE
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State | IL
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Zip | 62274-1700
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Country | US
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Telephone | 618-357-5371
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Fax | 618-357-3190
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Provider Business Mailing Address
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Address Line | PO BOX 49
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City | PINCKNEYVILLE
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State | IL
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Zip | 62274-0049
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Country | US
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Telephone | 618-357-5371
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Fax | 618-357-3190
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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 | 163WC1500X
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Taxonomy Name | Community Health Registered Nurse
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License Number | 041.276442
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License Number State | IL
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