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General NPI Number Information
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NPI Number | 1972849321
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Entity Type | Individual
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Provider Name | KELSEY WICKENHAUSER PA
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Gender | Female
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Dates
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Enumeration Date | 12/12/2012
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Last Update Date | 05/13/2014
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Provider Practice Location Address
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Address Line | 1368 DADRIAN PROFESSIONAL PARK
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City | GODFREY
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State | IL
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Zip | 62035-1685
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Country | US
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Telephone | 309-530-9841
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Fax |
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Provider Business Mailing Address
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Address Line | 8416 GANNON AVE
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City | SAINT LOUIS
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State | MO
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Zip | 63132-4907
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Country | US
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Telephone | 309-530-9841
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Fax |
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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 | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 2012037422
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 085 005 018
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License Number State | IL
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