Provider Demographics
NPI:1467067207
Name:WILCOX, MANDI NICOLE (ARNP, RN)
Entity Type:Individual
Prefix:
First Name:MANDI
Middle Name:NICOLE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:ARNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 335
Mailing Address - Street 2:
Mailing Address - City:NACHES
Mailing Address - State:WA
Mailing Address - Zip Code:98937-0335
Mailing Address - Country:US
Mailing Address - Phone:509-388-8074
Mailing Address - Fax:
Practice Address - Street 1:2811 TIETON DR
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3761
Practice Address - Country:US
Practice Address - Phone:509-575-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-09
Last Update Date:2020-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60435024163W00000X
WAAP61104820363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WARN60435024OtherWASHINGTON STATE DEPARTMENT OF HEALTH