Provider Demographics
NPI:1336325802
Name:STORK, VICKI LOU
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:LOU
Last Name:STORK
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 1:131 W 3RD ST.
Mailing Address - Street 2:
Mailing Address - City:GLIDDEN
Mailing Address - State:IA
Mailing Address - Zip Code:51443
Mailing Address - Country:US
Mailing Address - Phone:712-830-2511
Mailing Address - Fax:
Practice Address - Street 1:311 S CLARK ST
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3038
Practice Address - Country:US
Practice Address - Phone:712-794-0826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA079618163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical