Healthcare Provider Details

I. General information

NPI: 1467067207
Provider Name (Legal Business Name): MANDI NICOLE WILCOX ARNP, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2020
Last Update Date: 11/05/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2811 TIETON DR
YAKIMA WA
98902-3761
US

IV. Provider business mailing address

PO BOX 335
NACHES WA
98937-0335
US

V. Phone/Fax

Practice location:
  • Phone: 509-575-8100
  • Fax:
Mailing address:
  • Phone: 509-388-8074
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP61104820
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60435024
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: