Provider Demographics
NPI:1043710015
Name:VERGE, MKIJUAN (LVN)
Entity Type:Individual
Prefix:
First Name:MKIJUAN
Middle Name:
Last Name:VERGE
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 PARR ST
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-4447
Mailing Address - Country:US
Mailing Address - Phone:806-513-9552
Mailing Address - Fax:
Practice Address - Street 1:6300 W I 40
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2523
Practice Address - Country:US
Practice Address - Phone:806-353-2700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-16
Last Update Date:2018-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX336817164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse