Provider Demographics
NPI:1093856130
Name:WICKS, FUSAE MARY (NP)
Entity type:Individual
Prefix:MRS
First Name:FUSAE
Middle Name:MARY
Last Name:WICKS
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:7104 CARMEN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-3430
Mailing Address - Country:US
Mailing Address - Phone:702-994-7267
Mailing Address - Fax:702-623-5995
Practice Address - Street 1:4560 S EASTERN AVE STE 15
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-6182
Practice Address - Country:US
Practice Address - Phone:702-994-7267
Practice Address - Fax:702-623-5995
Is Sole Proprietor?:No
Enumeration Date:2007-02-10
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV813615363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner