Provider Demographics
NPI:1598316374
Name:WILCOXEN, MARTHA
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:WILCOXEN
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 1:360 DEPOT RD
Mailing Address - Street 2:
Mailing Address - City:KEATCHIE
Mailing Address - State:LA
Mailing Address - Zip Code:71046-5202
Mailing Address - Country:US
Mailing Address - Phone:318-464-5554
Mailing Address - Fax:
Practice Address - Street 1:360 DEPOT RD
Practice Address - Street 2:
Practice Address - City:KEATCHIE
Practice Address - State:LA
Practice Address - Zip Code:71046-5202
Practice Address - Country:US
Practice Address - Phone:318-464-5544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA0032723583747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA003272358OtherHEALTH CARE TECHNICIAN