Provider Demographics
NPI:1033580394
Name:ST JOHN, VICKY (APRN)
Entity Type:Individual
Prefix:
First Name:VICKY
Middle Name:
Last Name:ST JOHN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:JASPER
Mailing Address - State:TX
Mailing Address - Zip Code:75951-4013
Mailing Address - Country:US
Mailing Address - Phone:409-384-3430
Mailing Address - Fax:409-383-1054
Practice Address - Street 1:315 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:TX
Practice Address - Zip Code:75951-4013
Practice Address - Country:US
Practice Address - Phone:409-384-3430
Practice Address - Fax:409-383-1054
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-13
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129324363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily