1336269380 NPI number — MRS. VICKI LYNNE NORDGULEN LPC

Table of content: MRS. VICKI LYNNE NORDGULEN LPC (NPI 1336269380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336269380 NPI number — MRS. VICKI LYNNE NORDGULEN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NORDGULEN
Provider First Name:
VICKI
Provider Middle Name:
LYNNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPC
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:
1336269380
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 569
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INGRAM
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78025-0569
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
830-367-4848
Provider Business Mailing Address Fax Number:
830-367-7331

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3352 JUNCTION HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGRAM
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78025-3267
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
830-367-4848
Provider Business Practice Location Address Fax Number:
830-367-7331
Provider Enumeration Date:
03/30/2007

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: 101YP2500X , with the licence number:  14065 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 027727901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com