Provider Demographics
NPI:1316599780
Name:CARLSON, VICKI
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:CARLSON
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 1:367 S UNION ST
Mailing Address - Street 2:
Mailing Address - City:PARMA
Mailing Address - State:MI
Mailing Address - Zip Code:49269-9418
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:367 S UNION ST
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:MI
Practice Address - Zip Code:49269-9418
Practice Address - Country:US
Practice Address - Phone:517-262-1069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2019-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244915163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse