Individual
MS. LAURA MARIE WICKLINE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PMHNP
Contact information
Practice address
1132 SW 13TH AVE, PORTLAND, OR 97205-1703
(503) 484-3341
Mailing address
1132 SW 13TH AVE, PORTLAND, OR 97205-1703
(503) 484-3341
Taxonomy
Speciality
Code
Description
License number
State
163WP0808X
Psychiatric/Mental Health Registered Nurse
200442418RN
OR
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
200950021NP
OR
Other
Enumeration date
07/15/2008
Last updated
02/08/2012
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