Provider Demographics
NPI:1164411559
Name:DEWEESE, VICKI R (FNP-BC)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:R
Last Name:DEWEESE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 REED RD STE 104
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-6307
Mailing Address - Country:US
Mailing Address - Phone:706-529-8710
Mailing Address - Fax:706-529-8715
Practice Address - Street 1:475 REED RD STE 104
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-6307
Practice Address - Country:US
Practice Address - Phone:706-529-8710
Practice Address - Fax:706-529-8715
Is Sole Proprietor?:No
Enumeration Date:2005-10-18
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6358363L00000X
GARN145900363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000848658Medicaid
202I5400663Medicare PIN