Provider Demographics
NPI:1194333831
Name:WICKLUND, WHITNEY LAYNE
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:LAYNE
Last Name:WICKLUND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:375 SHEFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-2027
Mailing Address - Country:US
Mailing Address - Phone:612-834-0628
Mailing Address - Fax:
Practice Address - Street 1:519 BROADWAY
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-2822
Practice Address - Country:US
Practice Address - Phone:718-447-5437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-20
Last Update Date:2023-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY697194-01163W00000X
NYF04220230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse