Provider Demographics
NPI:1629140660
Name:WILCOXEN-ROSE, PAMELA ANNE (DC)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:ANNE
Last Name:WILCOXEN-ROSE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:PAMELA
Other - Middle Name:A
Other - Last Name:WILCOXEN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:4410 N KNOXVILLE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-6083
Mailing Address - Country:US
Mailing Address - Phone:309-685-8071
Mailing Address - Fax:
Practice Address - Street 1:4410 N KNOXVILLE AVE STE E
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-6083
Practice Address - Country:US
Practice Address - Phone:309-685-8071
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-006551111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
940140Medicare ID - Type Unspecified