MEDICARE: MS. SHANNON NICOLE WILCOX PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT60099667	WA

General Provider Information

NPI Number	:	1598996118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. SHANNON NICOLE WILCOX PT

Provider Business Mailing Address
First Line	:	18504 BOTHELL WAY NE
Second Line	:
City	:	BOTHELL
State	:	WA
Zip	:	98011-1927
Country	:	US
Telephone Number	:	425-481-1933
Fax Number	:	425-481-9371

Provider Business Practice Location Address
First Line	:	2108 CATON WAY SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98502-1105
Country	:	US
Telephone Number	:	360-352-1126
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2009
Last Update Date	:	08/11/2020

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