Provider Demographics
NPI:1093225252
Name:MACINTOSH, VIKKI LYNNE (LPN)
Entity Type:Individual
Prefix:MRS
First Name:VIKKI
Middle Name:LYNNE
Last Name:MACINTOSH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 CRAIG RD
Mailing Address - Street 2:
Mailing Address - City:ISLIP TERRACE
Mailing Address - State:NY
Mailing Address - Zip Code:11752-1920
Mailing Address - Country:US
Mailing Address - Phone:631-513-1177
Mailing Address - Fax:
Practice Address - Street 1:60 CRAIG RD
Practice Address - Street 2:
Practice Address - City:ISLIP TERRACE
Practice Address - State:NY
Practice Address - Zip Code:11752-1920
Practice Address - Country:US
Practice Address - Phone:631-513-1177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-02
Last Update Date:2017-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY329027-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY093572136Medicaid