Provider Demographics
NPI:1417470162
Name:CARROLL, VICY WIGGINS (MN, RN, NP-C)
Entity Type:Individual
Prefix:
First Name:VICY
Middle Name:WIGGINS
Last Name:CARROLL
Suffix:
Gender:F
Credentials:MN, RN, NP-C
Other - Prefix:
Other - First Name:VICY
Other - Middle Name:LYN
Other - Last Name:WIGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BSN, RN, RNFA
Mailing Address - Street 1:1100 WARD STREET EXT W
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31533-1902
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:
Practice Address - Street 1:1622 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3756
Practice Address - Country:US
Practice Address - Phone:229-387-8061
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN086037363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN086037OtherMEDICAL LICENSE