Provider Demographics
NPI:1346297090
Name:MINNINGER, VICKY DIANNE (CFNP)
Entity Type:Individual
Prefix:MS
First Name:VICKY
Middle Name:DIANNE
Last Name:MINNINGER
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-6525
Mailing Address - Fax:601-984-6764
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:601-984-6525
Practice Address - Fax:601-984-6764
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR638633363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS500005456OtherRAILROAD
MS0118842Medicaid
AL105774Medicaid
512G700003OtherUP MEDICARE
MS500000302Medicare ID - Type Unspecified
MS0118842Medicaid
512G700003OtherUP MEDICARE
MS512I500058Medicare PIN