Provider Demographics
NPI:1982159828
Name:VICKERS, TARA (RN)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:VICKERS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 COLDEN CT
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-5002
Mailing Address - Country:US
Mailing Address - Phone:716-580-3665
Mailing Address - Fax:
Practice Address - Street 1:2470 ALLEN AVE
Practice Address - Street 2:
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14303-1908
Practice Address - Country:US
Practice Address - Phone:716-580-3556
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553163-1163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)