Provider Demographics
NPI:1225769011
Name:ENIX, VICKI LYNN
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:ENIX
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2038 MIDDLE GRAVE CREEK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-3352
Mailing Address - Country:US
Mailing Address - Phone:304-639-3761
Mailing Address - Fax:
Practice Address - Street 1:2038 MIDDLE GRAVE CREEK RD
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-3352
Practice Address - Country:US
Practice Address - Phone:304-639-3761
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WV1356607394Medicaid
WV125553494Medicaid