Provider Demographics
NPI:1992908008
Name:WICKWARE, CARRIE LEE (CDE)
Entity type:Individual
Prefix:
First Name:CARRIE
Middle Name:LEE
Last Name:WICKWARE
Suffix:
Gender:F
Credentials:CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1590 QUEENSBURY AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5843
Mailing Address - Country:US
Mailing Address - Phone:650-903-0889
Mailing Address - Fax:
Practice Address - Street 1:750 S BASCOM AVE
Practice Address - Street 2:DIABETES ED
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2603
Practice Address - Country:US
Practice Address - Phone:408-885-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARNH321148163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator