Provider Demographics
NPI:1508826322
Name:WLOCK, VICKI M (NP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:M
Last Name:WLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:915 ORCHARD DR
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092-1815
Mailing Address - Country:US
Mailing Address - Phone:716-523-0539
Mailing Address - Fax:
Practice Address - Street 1:6934 WILLIAMS RD
Practice Address - Street 2:SUITE 500
Practice Address - City:NIAGARA FALLS
Practice Address - State:NY
Practice Address - Zip Code:14304-3080
Practice Address - Country:US
Practice Address - Phone:716-297-7898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY370695163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02521740Medicaid
NYRA9663Medicare ID - Type Unspecified
NYS70283Medicare UPIN