Individual
KELSEY WICKENHAUSER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
1368 DADRIAN PROFESSIONAL PARK, GODFREY, IL 62035-1685
(309) 530-9841
Mailing address
8416 GANNON AVE, SAINT LOUIS, MO 63132-4907
(309) 530-9841
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085 005 018
IL
363A00000X
Physician Assistant
2012037422
MO
Other
Enumeration date
12/12/2012
Last updated
05/13/2014
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