Basic Information
| Provider Information | |||||||||
| NPI: | 1831829233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKERSHAM | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TRIVEDI | ||||||||
| OtherFirstName: | KAITLIN | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1101 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471528 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1101 MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LOGANSPORT | ||||||||
| State: | IN | ||||||||
| PostalCode: | 469471528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5747537541 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2022 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71012651A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.