Provider Demographics
NPI:1396225611
Name:VICKERMAN, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:VICKERMAN
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 1:2266 76TH AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-7405
Mailing Address - Country:US
Mailing Address - Phone:719-323-7634
Mailing Address - Fax:
Practice Address - Street 1:1555 N 17TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80631-9117
Practice Address - Country:US
Practice Address - Phone:970-304-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY49802363LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine