Provider Demographics
NPI:1306312046
Name:WILCOX, KANISA (LPN)
Entity type:Individual
Prefix:
First Name:KANISA
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9568 WOODSTATE DR # 13A
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45251-2303
Mailing Address - Country:US
Mailing Address - Phone:513-225-8301
Mailing Address - Fax:
Practice Address - Street 1:9568 WOODSTATE DR # 13A
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45251-2303
Practice Address - Country:US
Practice Address - Phone:513-225-8301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-21
Last Update Date:2018-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH152935164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse