Provider Demographics
NPI:1326433301
Name:WILLCOCKSON, KATIE ANNE (MD)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ANNE
Last Name:WILLCOCKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:ANNE
Other - Last Name:KENEALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:9000 W WISCONSIN AVE # MS 958
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4874
Mailing Address - Country:US
Mailing Address - Phone:414-266-7615
Mailing Address - Fax:414-266-6238
Practice Address - Street 1:4855 S MOORLAND RD
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-7494
Practice Address - Country:US
Practice Address - Phone:262-432-7599
Practice Address - Fax:262-432-7694
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-06
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10100590-1205208000000X
WI75410-20208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1326433301Medicaid