Basic Information
| Provider Information | |||||||||
| NPI: | 1619160827 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LANDRY | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | 1ST ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6049 JADE AVE | ||||||||
| Address2: | |||||||||
| City: | PORT ARTHUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776401132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097363584 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5500 39TH ST | ||||||||
| Address2: | |||||||||
| City: | GROVES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 776192905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4099625733 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2007 | ||||||||
| LastUpdateDate: | 08/21/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZS0410X | 06-246 | TX | Y |
No ID Information.