Basic Information
| Provider Information | |||||||||
| NPI: | 1215912027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILCOXSON | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864250141 | ||||||||
| FaxNumber: | 3862264577 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 N CLYDE MORRIS BLVD STE 302 | ||||||||
| Address2: | |||||||||
| City: | DAYTONA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321142709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3864254542 | ||||||||
| FaxNumber: | 3864257705 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2005 | ||||||||
| LastUpdateDate: | 06/29/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN536557 | PA | N | Nursing Service Providers | Registered Nurse | 363LA2100X | SP007353 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 363LA2100X | ARNP9438475 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | SP007353 | 01 | PA | LICENSE | OTHER | 867633 | 01 | PA | MEDICARE GROUP # | OTHER | 1007307260034 | 01 | PA | MEDICAID GROUP # | OTHER | 25-1716306 | 01 | PA | DEVON | OTHER | MW1032729 | 01 | PA | DEA | OTHER |