Basic Information
| Provider Information | |||||||||
| NPI: | 1851723555 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WICKWIRE | ||||||||
| FirstName: | ADRIENNE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | DPT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | BEAUDUY | ||||||||
| OtherFirstName: | ADRIENNE | ||||||||
| OtherMiddleName: | L | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1005 CRYSTAL CREEK DR | ||||||||
| Address2: | |||||||||
| City: | MECHANICSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170501966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7175546140 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2250 MILLENNIUM WAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ENOLA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170251488 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177328131 | ||||||||
| FaxNumber: | 7177328132 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2013 | ||||||||
| LastUpdateDate: | 04/22/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT022809 | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251X0800X | PT022809 | PA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.