Provider Demographics
NPI:1043599970
Name:DURHAM, VICKIE CHRISTINE (BS)
Entity Type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:CHRISTINE
Last Name:DURHAM
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4809 HIGHWAY 67
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-7867
Mailing Address - Country:US
Mailing Address - Phone:501-425-9616
Mailing Address - Fax:
Practice Address - Street 1:9880 BROCKINGTON RD
Practice Address - Street 2:SUITE 147
Practice Address - City:SHERWOOD
Practice Address - State:AR
Practice Address - Zip Code:72120-3585
Practice Address - Country:US
Practice Address - Phone:501-944-7819
Practice Address - Fax:501-251-1165
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR811225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist