MEDICARE: MS. CECILIA M WICKERT

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	231H00000X	Audiologist	AY871	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	4899832	OTHER	FL	GHI
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1942230842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CECILIA M WICKERT

Provider Business Mailing Address
First Line	:	PO BOX 406153
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30384-1876
Country	:	US
Telephone Number	:	561-478-8770
Fax Number	:	561-688-8877

Provider Business Practice Location Address
First Line	:	729 CORTARO DR
Second Line	:
City	:	RUSKIN
State	:	FL
Zip	:	33573-6812
Country	:	US
Telephone Number	:	813-633-0842
Fax Number	:

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

Provider Enumeration Date	:	07/04/2006
Last Update Date	:	10/09/2008

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