MEDICARE: JACQUELINE WICHERN

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	363L00000X	Nurse Practitioner	5010338	NC
2	363L00000X	Nurse Practitioner	0024185446	VA

General Provider Information

NPI Number	:	1053813105
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE WICHERN

Provider Business Mailing Address
First Line	:	101 E WT HARRIS BLVD
Second Line	:	BUILDING 1000 SUITE 1110
City	:	CHARLOTTE
State	:	NC
Zip	:	28262-3485
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1005 N GLEBE RD STE 160
Second Line	:
City	:	ARLINGTON
State	:	VA
Zip	:	22201-5758
Country	:	US
Telephone Number	:	571-472-6464
Fax Number	:

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

Provider Enumeration Date	:	03/05/2018
Last Update Date	:	04/01/2024

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Directions to “ JACQUELINE WICHERN ” Practice Location

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