Provider Demographics
NPI:1699324905
Name:WILCOX, MARY LETICIA
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:LETICIA
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:PO BOX 509
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:24605-0509
Mailing Address - Country:US
Mailing Address - Phone:210-410-1507
Mailing Address - Fax:
Practice Address - Street 1:52 BRIARWOOD LN
Practice Address - Street 2:
Practice Address - City:ROCKY GAP
Practice Address - State:VA
Practice Address - Zip Code:24366-7112
Practice Address - Country:US
Practice Address - Phone:210-410-1507
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-09
Last Update Date:2019-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider