Provider Demographics
NPI:1104226596
Name:WICKER, VENINA (RN)
Entity type:Individual
Prefix:
First Name:VENINA
Middle Name:
Last Name:WICKER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1061 HARMON AVE
Mailing Address - Street 2:BLDG 302
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-6793
Mailing Address - Fax:
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:BLDG 302
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-6793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9311561163W00000X, 163WA2000X, 163WE0003X, 163WM0102X, 163WM0705X, 163WP0200X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WA2000XNursing Service ProvidersRegistered NurseAdministrator
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9311561OtherRN