Provider Demographics
NPI:1063021889
Name:WILCOX, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 NW WAYNE PL APT 105
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-6107
Mailing Address - Country:US
Mailing Address - Phone:904-535-5206
Mailing Address - Fax:
Practice Address - Street 1:1447 NW WAYNE PL APT 105
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-6107
Practice Address - Country:US
Practice Address - Phone:904-535-5206
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant