Basic Information
Provider Information | |||||||||
NPI: | 1558621193 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VICE | ||||||||
FirstName: | ANDREA | ||||||||
MiddleName: | MICHELLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1125 CARTHAGE ST | ||||||||
Address2: |   | ||||||||
City: | SANFORD | ||||||||
State: | NC | ||||||||
PostalCode: | 273304162 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9197746023 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3351 S PEAK DR STE 101 | ||||||||
Address2: |   | ||||||||
City: | FAYETTEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 283069693 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9109084673 | ||||||||
FaxNumber: | 9109082242 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2012 | ||||||||
LastUpdateDate: | 11/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Q2865 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2015-00956 | NC | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.