1770925794 NPI number — DR. AMANDA M VICKERS D.O

Table of content: DR. AMANDA M VICKERS D.O (NPI 1770925794)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770925794 NPI number — DR. AMANDA M VICKERS D.O

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VICKERS
Provider First Name:
AMANDA
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VICKERS
Provider Other First Name:
MISTY
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
D.O
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1770925794
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 936
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONDON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40743-0936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
859-858-9355
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
200 RICE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WILMORE
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40390-1359
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-858-9355
Provider Business Practice Location Address Fax Number:
859-858-0416
Provider Enumeration Date:
07/18/2013

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: 207Q00000X , with the licence number:  2018036866 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: TP038 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200064469 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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