Provider Demographics
NPI:1821195595
Name:WARD, VICKI D (MS FNP PSYCH NP)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:D
Last Name:WARD
Suffix:
Gender:F
Credentials:MS FNP PSYCH NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12127 HWY 14 N STE 5B
Mailing Address - Street 2:
Mailing Address - City:CEDAR CREST
Mailing Address - State:NM
Mailing Address - Zip Code:87008-9461
Mailing Address - Country:US
Mailing Address - Phone:508-776-6153
Mailing Address - Fax:
Practice Address - Street 1:1108 W US ROUTE 66
Practice Address - Street 2:
Practice Address - City:MORIARTY
Practice Address - State:NM
Practice Address - Zip Code:87035-1006
Practice Address - Country:US
Practice Address - Phone:505-832-4434
Practice Address - Fax:505-832-5024
Is Sole Proprietor?:No
Enumeration Date:2006-09-17
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02142363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0799963Medicaid
MA20-3014445OtherTAX ID NUMBER
MA20-3014445OtherTAX ID NUMBER
MA0799963Medicaid