1255363826 NPI number — VICKIE C. WADE WHNP-C

Table of content: VICKIE C. WADE WHNP-C (NPI 1255363826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255363826 NPI number — VICKIE C. WADE WHNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WADE
Provider First Name:
VICKIE
Provider Middle Name:
C.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
WHNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FRAGER
Provider Other First Name:
VICKIE
Provider Other Middle Name:
C.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
ANP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1255363826
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/22/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5701 DELMAR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63112-2617
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-367-7848
Provider Business Mailing Address Fax Number:
314-367-2985

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5701 DELMAR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63112-2617
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-367-7848
Provider Business Practice Location Address Fax Number:
314-367-2985
Provider Enumeration Date:
07/06/2006

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: 363LW0102X , with the licence number:  RN095910 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LW0102X , with the licence number: 095910 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 423909811 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".