Provider Demographics
NPI:1063166858
Name:WICKER, NATAVIA M (OTA)
Entity type:Individual
Prefix:
First Name:NATAVIA
Middle Name:M
Last Name:WICKER
Suffix:
Gender:F
Credentials:OTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1169 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-5355
Mailing Address - Country:US
Mailing Address - Phone:904-672-6469
Mailing Address - Fax:
Practice Address - Street 1:8171 JOFFRE DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-2416
Practice Address - Country:US
Practice Address - Phone:904-672-6479
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health