Basic Information
| Provider Information | |||||||||
| NPI: | 1396058707 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VICKERS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2239 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356092239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 1201 7TH ST SE | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | AL | ||||||||
| PostalCode: | 356013337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2563412000 | ||||||||
| FaxNumber: | 2563061691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2010 | ||||||||
| LastUpdateDate: | 01/25/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | ARNP9306515 | FL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 1-102952 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 002708400 | 05 | FL | MEDICAID |