Provider Demographics
NPI:1881641736
Name:WILCOX, JULIE A (OTR)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:WILCOX
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:A
Other - Last Name:BUCKNAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTR
Mailing Address - Street 1:20 E STIRRUP TRL
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-7704
Mailing Address - Country:US
Mailing Address - Phone:719-487-8121
Mailing Address - Fax:719-487-8121
Practice Address - Street 1:20 E STIRRUP TRL
Practice Address - Street 2:
Practice Address - City:MONUMENT
Practice Address - State:CO
Practice Address - Zip Code:80132-7704
Practice Address - Country:US
Practice Address - Phone:719-487-8121
Practice Address - Fax:719-487-8121
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO006629174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO30780373Medicaid