Healthcare Provider Details

I. General information

NPI: 1396080024
Provider Name (Legal Business Name): ROSE CAROLYN WILCOX A.C.N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14411 SMUGGLERS NOTCH SUITE A
FORT WAYNE IN
46814-8701
US

IV. Provider business mailing address

1197 US HIGHWAY 6
EDGERTON OH
43517-9701
US

V. Phone/Fax

Practice location:
  • Phone: 260-515-3275
  • Fax: 888-803-6843
Mailing address:
  • Phone: 604-457-0802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number71004246A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71004246A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: