MEDICARE: MRS. VANESSA MICHELLE WICKHAM NP, CNS

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	363LA2200X	Adult Health Nurse Practitioner	NP95030225	CA

General Provider Information

NPI Number	:	1720817018
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. VANESSA MICHELLE WICKHAM NP, CNS

Provider Business Mailing Address
First Line	:	5241 JAMESTOWN RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-1244
Country	:	US
Telephone Number	:	714-824-7838
Fax Number	:

Provider Business Practice Location Address
First Line	:	4731 CLAIREMONT DR # 100
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92117-2743
Country	:	US
Telephone Number	:	714-824-7838
Fax Number	:

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

Provider Enumeration Date	:	07/26/2024
Last Update Date	:	07/26/2024

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