Provider Demographics
NPI:1326255266
Name:WILCOX, LISA M
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:M
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 1:8645 TOWNSHIP ROAD 34
Mailing Address - Street 2:
Mailing Address - City:GALION
Mailing Address - State:OH
Mailing Address - Zip Code:44833-9796
Mailing Address - Country:US
Mailing Address - Phone:419-468-1728
Mailing Address - Fax:
Practice Address - Street 1:516 KILBURY RD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-4533
Practice Address - Country:US
Practice Address - Phone:740-387-7466
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2481274Medicaid