Provider Demographics
NPI:1083788665
Name:LARY, VICKI NICOLE (CFNP)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:NICOLE
Last Name:LARY
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:NICKI
Other - Middle Name:BOGGAN
Other - Last Name:LARY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CFNP
Mailing Address - Street 1:2207 RIVER ROAD EXTENDED
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:38930
Mailing Address - Country:US
Mailing Address - Phone:662-451-9984
Mailing Address - Fax:
Practice Address - Street 1:103 BASKET ST
Practice Address - Street 2:
Practice Address - City:ITTA BENA
Practice Address - State:MS
Practice Address - Zip Code:38941-2801
Practice Address - Country:US
Practice Address - Phone:662-254-7801
Practice Address - Fax:662-254-9173
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR860262363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily