Provider Demographics
NPI:1376701888
Name:MIRACLE, VICKI LYNN (RN)
Entity Type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:LYNN
Last Name:MIRACLE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19824 S BUTTE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OR
Mailing Address - Zip Code:97004-8847
Mailing Address - Country:US
Mailing Address - Phone:503-632-7077
Mailing Address - Fax:503-336-1850
Practice Address - Street 1:19824 S BUTTE RD
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OR
Practice Address - Zip Code:97004-8847
Practice Address - Country:US
Practice Address - Phone:503-632-7077
Practice Address - Fax:503-336-1850
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-30
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR090000670RN163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health