Provider Demographics
NPI:1699528901
Name:WICHERT, ANGELA MAE (LPN,WCC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:MAE
Last Name:WICHERT
Suffix:
Gender:F
Credentials:LPN,WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 S CLARENCE NASH BLVD
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-4820
Mailing Address - Country:US
Mailing Address - Phone:580-623-4991
Mailing Address - Fax:580-623-5490
Practice Address - Street 1:1305 S CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-4820
Practice Address - Country:US
Practice Address - Phone:580-623-4991
Practice Address - Fax:580-623-5490
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKL0056224164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse