Provider Demographics
NPI:1528393493
Name:WILCOX, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:914 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32401-2528
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32401-2528
Practice Address - Country:US
Practice Address - Phone:850-747-5411
Practice Address - Fax:850-747-5583
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker