Provider Demographics
NPI:1437751617
Name:VICKERS, MAGDALYN MAY
Entity Type:Individual
Prefix:
First Name:MAGDALYN
Middle Name:MAY
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 1:860 E RIVER PL STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-3442
Mailing Address - Country:US
Mailing Address - Phone:769-251-5550
Mailing Address - Fax:769-251-5590
Practice Address - Street 1:3452 PASCAGOULA ST STE 3
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-3203
Practice Address - Country:US
Practice Address - Phone:228-712-8024
Practice Address - Fax:228-712-8027
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker