Provider Demographics
NPI:1558633370
Name:MERRITT, VICKI LYNN (BA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:MERRITT
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:LYNN
Other - Last Name:VAN IDISTINE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6350 W A J HWY
Mailing Address - Street 2:DEPARTMENT 100
Mailing Address - City:TALBOTT
Mailing Address - State:TN
Mailing Address - Zip Code:37877-8605
Mailing Address - Country:US
Mailing Address - Phone:800-355-3565
Mailing Address - Fax:423-714-2355
Practice Address - Street 1:120 HOSPITAL DR
Practice Address - Street 2:SUITE 230
Practice Address - City:JEFFERSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37760-5287
Practice Address - Country:US
Practice Address - Phone:865-471-0312
Practice Address - Fax:865-475-2802
Is Sole Proprietor?:No
Enumeration Date:2012-02-09
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator