Basic Information
Provider Information
NPI: 1033580048
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WICK
FirstName: CYNTHIA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LPN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 43 SCOTT LN
Address2:  
City: PHILIPSBURG
State: PA
PostalCode: 168668550
CountryCode: US
TelephoneNumber: 8143425678
FaxNumber: 8143422755
Practice Location
Address1: 1633 PHILIPSBURG BIGLER HWY
Address2:  
City: PHILIPSBURG
State: PA
PostalCode: 168668112
CountryCode: US
TelephoneNumber: 8143425678
FaxNumber: 8143422755
Other Information
ProviderEnumerationDate: 10/16/2015
LastUpdateDate: 10/16/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
164W00000XPN071500LPAY Nursing Service ProvidersLicensed Practical Nurse 

ID Information
IDTypeStateIssuerDescription
00188805305PA MEDICAID


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