Healthcare Provider Details

I. General information

NPI: 1881902690
Provider Name (Legal Business Name): THERESA WILCOX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2010
Last Update Date: 06/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2046 ALLEN AVE
ALTADENA CA
91001-3424
US

IV. Provider business mailing address

2046 ALLEN AVE
ALTADENA CA
91001-3424
US

V. Phone/Fax

Practice location:
  • Phone: 626-396-5920
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number396499
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number396499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: