Provider Demographics
NPI:1285793570
Name:VICK, POLLY T (FNP)
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:T
Last Name:VICK
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 E. RANCIER AVE, STE 103
Mailing Address - Street 2:
Mailing Address - City:KILLEEN
Mailing Address - State:TX
Mailing Address - Zip Code:76543-3450
Mailing Address - Country:US
Mailing Address - Phone:254-200-2310
Mailing Address - Fax:254-200-2340
Practice Address - Street 1:2300 E. RANCIER AVE, STE 103
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76543-3450
Practice Address - Country:US
Practice Address - Phone:254-200-2310
Practice Address - Fax:254-200-2340
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2015-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX675722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily