1962751677 NPI number — MRS. TRICIA VICK GILLIAN MASTERS, SSP

Table of content: MRS. TRICIA VICK GILLIAN MASTERS, SSP (NPI 1962751677)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962751677 NPI number — MRS. TRICIA VICK GILLIAN MASTERS, SSP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GILLIAN
Provider First Name:
TRICIA
Provider Middle Name:
VICK
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MASTERS, SSP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
VICK
Provider Other First Name:
TRICIA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MASTERS, SSP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1962751677
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
811 BRADBERRY LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDIAN TRAIL
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28079-5104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
252-904-4426
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
811 BRADBERRY LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INDIAN TRAIL
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28079-5104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
252-904-4426
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/10/2012

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: 103T00000X , with the licence number:  4328 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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