Basic Information
| Provider Information | |||||||||
| NPI: | 1265103394 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VICKERS | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 70 TERI LN | ||||||||
| Address2: | |||||||||
| City: | LITTLE HOCKING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457429608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7404182409 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1106 COLEGATE DR | ||||||||
| Address2: | |||||||||
| City: | MARIETTA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 457501323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7405682000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2021 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 110905 | WV | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163WM0705X | RN.298491 | OH | Y | Nursing Service Providers | Registered Nurse | Medical-Surgical |
No ID Information.