Provider Demographics
NPI:1528494150
Name:VICKERS, SHANNON E (NP)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:E
Last Name:VICKERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1510
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47706-1510
Mailing Address - Country:US
Mailing Address - Phone:812-479-3453
Mailing Address - Fax:812-473-8166
Practice Address - Street 1:6221 PHYSICIANS CT
Practice Address - Street 2:STE 1
Practice Address - City:EVANSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47715-4031
Practice Address - Country:US
Practice Address - Phone:812-479-3453
Practice Address - Fax:812-473-8166
Is Sole Proprietor?:No
Enumeration Date:2013-09-14
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004620A363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily