Provider Demographics
NPI:1720817018
Name:WICKHAM, VANESSA MICHELLE (NP, CNS)
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:MICHELLE
Last Name:WICKHAM
Suffix:
Gender:F
Credentials:NP, CNS
Other - Prefix:MISS
Other - First Name:VANESSA
Other - Middle Name:MICHELLE
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5241 JAMESTOWN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-1244
Mailing Address - Country:US
Mailing Address - Phone:714-824-7838
Mailing Address - Fax:
Practice Address - Street 1:4731 CLAIREMONT DR # 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-2743
Practice Address - Country:US
Practice Address - Phone:714-824-7838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-26
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95030225363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health