Provider Demographics
NPI:1083379721
Name:WICKERT, ASHLEY (APN)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:WICKERT
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 EAGLE ROCK AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:ROSELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:07068-1335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:188 EAGLE ROCK AVE STE 2A
Practice Address - Street 2:
Practice Address - City:ROSELAND
Practice Address - State:NJ
Practice Address - Zip Code:07068-1335
Practice Address - Country:US
Practice Address - Phone:973-435-6644
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-08
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01227200363LF0000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily