Provider Demographics
NPI:1760758742
Name:WILCOXEN, KATHIRENE ANN (MD)
Entity Type:Individual
Prefix:
First Name:KATHIRENE
Middle Name:ANN
Last Name:WILCOXEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KATHIRENE
Other - Middle Name:ANN
Other - Last Name:KLEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1028
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:IN
Mailing Address - Zip Code:47547-1028
Mailing Address - Country:US
Mailing Address - Phone:812-996-1088
Mailing Address - Fax:
Practice Address - Street 1:721 W 13TH ST
Practice Address - Street 2:SUITE 321
Practice Address - City:JASPER
Practice Address - State:IN
Practice Address - Zip Code:47546-1855
Practice Address - Country:US
Practice Address - Phone:812-996-7918
Practice Address - Fax:812-996-1644
Is Sole Proprietor?:No
Enumeration Date:2012-03-23
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075220208000000X
KY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics