Provider Demographics
NPI:1407281660
Name:VICKERS, MONICA
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:
Last Name:VICKERS
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 1:2313 MAMMOTH GROVE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33898-8583
Mailing Address - Country:US
Mailing Address - Phone:863-206-6439
Mailing Address - Fax:
Practice Address - Street 1:2313 MAMMOTH GROVE RD
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33898-8583
Practice Address - Country:US
Practice Address - Phone:863-206-6439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906570311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006792400Medicaid