Provider Demographics
NPI:1568447167
Name:VICK, GRETCHEN P (NP)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:P
Last Name:VICK
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 1:701 DOCTORS DR
Mailing Address - Street 2:SUITE N
Mailing Address - City:KINSTON
Mailing Address - State:NC
Mailing Address - Zip Code:28501-1584
Mailing Address - Country:US
Mailing Address - Phone:252-559-2200
Mailing Address - Fax:252-522-9778
Practice Address - Street 1:313 AIRPORT RD
Practice Address - Street 2:
Practice Address - City:KINSTON
Practice Address - State:NC
Practice Address - Zip Code:28501
Practice Address - Country:US
Practice Address - Phone:252-559-2200
Practice Address - Fax:252-522-9778
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9000380363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P88433Medicare UPIN
2808510Medicare ID - Type Unspecified