Basic Information
| Provider Information | |||||||||
| NPI: | 1104481175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILCOX | ||||||||
| FirstName: | KELLIE | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 190 | ||||||||
| Address2: | |||||||||
| City: | TOPPENISH | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989480190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098652395 | ||||||||
| FaxNumber: | 5098650757 | ||||||||
| Practice Location | |||||||||
| Address1: | 255 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015155 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035768400 | ||||||||
| FaxNumber: | 5033640775 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2019 | ||||||||
| LastUpdateDate: | 10/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 201391227 | OR | N | Nursing Service Providers | Registered Nurse | 163W00000X | 201391227RN | OR | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP61198829 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 202210366NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.