Provider Demographics
NPI:1033285721
Name:THEIS-MULHERIN, VICKI RENE (RN)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:RENE
Last Name:THEIS-MULHERIN
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 1:3421 MIKE PADGETT HWY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-3815
Mailing Address - Country:US
Mailing Address - Phone:706-432-4858
Mailing Address - Fax:706-432-3780
Practice Address - Street 1:3421 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-432-4858
Practice Address - Fax:706-432-3780
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN078133261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP 2010Medicare ID - Type Unspecified