Provider Demographics
NPI:1306861398
Name:VICKNAIR, JENNIFER ELIZABETH (CRNA)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
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 1:443 FIDDLERS CREEK DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-1774
Mailing Address - Country:US
Mailing Address - Phone:318-381-2130
Mailing Address - Fax:
Practice Address - Street 1:778 SCOGIN DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-5729
Practice Address - Country:US
Practice Address - Phone:870-367-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04334367500000X
LARN087113163W00000X
ARC003168367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1179272Medicaid
LA4C911 CM62Medicare PIN
LA1179272Medicaid