Provider Demographics
NPI:1275054017
Name:VICKERS, DENISE DARLENE (SA-C/CST)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:DARLENE
Last Name:VICKERS
Suffix:
Gender:F
Credentials:SA-C/CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12208 GARNER RD
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77705-7574
Mailing Address - Country:US
Mailing Address - Phone:409-679-7128
Mailing Address - Fax:
Practice Address - Street 1:2830 CALDER ST
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1809
Practice Address - Country:US
Practice Address - Phone:409-899-7280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-02
Last Update Date:2017-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI16-647246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant