Provider Demographics
NPI:1366741373
Name:VICKS, LAVERN (MA)
Entity type:Individual
Prefix:MRS
First Name:LAVERN
Middle Name:
Last Name:VICKS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:577 BELCHER CIR
Mailing Address - Street 2:
Mailing Address - City:CAIRO
Mailing Address - State:GA
Mailing Address - Zip Code:39827-4307
Mailing Address - Country:US
Mailing Address - Phone:850-244-2469
Mailing Address - Fax:
Practice Address - Street 1:438 W BREVARD ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-1004
Practice Address - Country:US
Practice Address - Phone:850-224-2469
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-17
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide