Provider Demographics
NPI:1306419098
Name:VICKERS, DOMONIQUE
Entity Type:Individual
Prefix:
First Name:DOMONIQUE
Middle Name:
Last Name:VICKERS
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 1:15418 FIRE ROCK PL
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33573-0196
Mailing Address - Country:US
Mailing Address - Phone:813-498-9937
Mailing Address - Fax:
Practice Address - Street 1:15418 FIRE ROCK PL
Practice Address - Street 2:
Practice Address - City:RUSKIN
Practice Address - State:FL
Practice Address - Zip Code:33573-0196
Practice Address - Country:US
Practice Address - Phone:813-498-9937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11005306363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily