Provider Demographics
NPI:1528666518
Name:WILCOX, SHMEIKA
Entity type:Individual
Prefix:
First Name:SHMEIKA
Middle Name:
Last Name:WILCOX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3608 STONE RD SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5306
Mailing Address - Country:US
Mailing Address - Phone:678-768-0621
Mailing Address - Fax:
Practice Address - Street 1:3608 STONE RD SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30331-5306
Practice Address - Country:US
Practice Address - Phone:678-768-0621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACN0000104698374U00000X
GA621209090009246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Multi-Specialty
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA83-4540359Medicaid