Provider Demographics
NPI:1104481175
Name:WILCOX, KELLIE ELIZABETH (ARNP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:ELIZABETH
Last Name:WILCOX
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-0190
Mailing Address - Country:US
Mailing Address - Phone:509-865-2395
Mailing Address - Fax:509-865-0757
Practice Address - Street 1:255 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-5155
Practice Address - Country:US
Practice Address - Phone:503-576-8400
Practice Address - Fax:503-364-0775
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201391227RN163W00000X
WAAP61198829363LF0000X
OR202210366NP-PP363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily