MEDICARE: CARLY ANN WICKSELL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YS0200X	School Counselor

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	VFM244898	OTHER	FL	FLORIDA HEALTH CARE PLANS

General Provider Information

NPI Number	:	1013632330
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLY ANN WICKSELL

Provider Business Mailing Address
First Line	:	2255 SW 37TH WAY
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32607-4484
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2255 SW 37TH WAY
Second Line	:
City	:	GAINESVILLE
State	:	FL
Zip	:	32607-4484
Country	:	US
Telephone Number	:	386-882-2053
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2022
Last Update Date	:	10/10/2022

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Directions to “ CARLY ANN WICKSELL ” Practice Location

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