Provider Demographics
NPI:1821596073
Name:WILKES, VENICE LUCIA (PA-C)
Entity type:Individual
Prefix:
First Name:VENICE
Middle Name:LUCIA
Last Name:WILKES
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:VENICE
Other - Middle Name:LUCIA
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:412 N 200 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-4038
Practice Address - Country:US
Practice Address - Phone:435-713-2710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2025-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT904363A00000X
FL9110986363A00000X
UT11159450-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant