1588681324 NPI number — VICKIE CLOUS FNP

Table of content: VICKIE CLOUS FNP (NPI 1588681324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588681324 NPI number — VICKIE CLOUS FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLOUS
Provider First Name:
VICKIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588681324
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/23/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 188
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARANA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85653-0188
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-682-4111
Provider Business Mailing Address Fax Number:
520-818-3630

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
287 E HUNT HWY STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN TAN VALLEY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85143-5096
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-677-8282
Provider Business Practice Location Address Fax Number:
480-535-0962
Provider Enumeration Date:
07/17/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP2228 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 967995 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".