Provider Demographics
NPI:1790723864
Name:WILCOX, JANELL DIANE (PA)
Entity Type:Individual
Prefix:
First Name:JANELL
Middle Name:DIANE
Last Name:WILCOX
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8509 SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-3003
Mailing Address - Country:US
Mailing Address - Phone:734-620-0116
Mailing Address - Fax:
Practice Address - Street 1:19675 ALLEN RD
Practice Address - Street 2:
Practice Address - City:BROWNSTOWN TWP
Practice Address - State:MI
Practice Address - Zip Code:48183-1021
Practice Address - Country:US
Practice Address - Phone:313-492-0331
Practice Address - Fax:734-479-1408
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003918363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical