Provider Demographics
NPI:1962069633
Name:WICKMAN, KATHRYN
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WICKMAN
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 1:2846 AMBER WOOD PL
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-1236
Mailing Address - Country:US
Mailing Address - Phone:805-915-9602
Mailing Address - Fax:805-273-7208
Practice Address - Street 1:2846 AMBER WOOD PL
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-1236
Practice Address - Country:US
Practice Address - Phone:805-915-9602
Practice Address - Fax:805-273-7208
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-28
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA570176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife