Provider Demographics
NPI:1508149584
Name:EDEN, VICKI LOUISE (LPN)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:LOUISE
Last Name:EDEN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 E BETHANY HOME RD
Mailing Address - Street 2:APT. 15
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-2006
Mailing Address - Country:US
Mailing Address - Phone:602-245-4501
Mailing Address - Fax:
Practice Address - Street 1:1753 E 8TH AVE
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-3617
Practice Address - Country:US
Practice Address - Phone:480-472-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP032476164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse