Provider Demographics
NPI:1134100746
Name:VICKNAIR, THERESA BOURG (CRNA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:BOURG
Last Name:VICKNAIR
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 JENNIFER LN
Mailing Address - Street 2:
Mailing Address - City:LA PLACE
Mailing Address - State:LA
Mailing Address - Zip Code:70068-5806
Mailing Address - Country:US
Mailing Address - Phone:985-359-0599
Mailing Address - Fax:
Practice Address - Street 1:ST JAMES PARISH HOSIPITAL
Practice Address - Street 2:LOUISIANE AVE
Practice Address - City:LUTCHER
Practice Address - State:LA
Practice Address - Zip Code:70071
Practice Address - Country:US
Practice Address - Phone:225-869-5512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN059871163W00000X
LAAP01519367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered