Provider Demographics
NPI:1174307557
Name:WUSSOW, RIKELLE (NP)
Entity type:Individual
Prefix:
First Name:RIKELLE
Middle Name:
Last Name:WUSSOW
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:RIKELLE
Other - Middle Name:
Other - Last Name:SHOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:519 CALIFORNIA AVE APT 203
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-3944
Mailing Address - Country:US
Mailing Address - Phone:608-438-7119
Mailing Address - Fax:
Practice Address - Street 1:2121 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2303
Practice Address - Country:US
Practice Address - Phone:608-438-7119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-24
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026825363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner