Provider Demographics
NPI:1275665283
Name:WILCOX, TRACY NICOLE (PTA, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:NICOLE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:PTA, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14564 HAREWOOD CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-1718
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14564 HAREWOOD CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32258-1718
Practice Address - Country:US
Practice Address - Phone:904-307-9514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAL 26892255A2300X
FLPTA231532081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL$$$$$$$$$Medicaid