Provider Demographics
NPI:1578925046
Name:IVERSON, VICKI LYNNE (RN)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNNE
Last Name:IVERSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:LYNNE
Other - Last Name:SEVERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1407 ST. ANDREW ST.
Mailing Address - Street 2:
Mailing Address - City:LA CROSSE
Mailing Address - State:WI
Mailing Address - Zip Code:54603
Mailing Address - Country:US
Mailing Address - Phone:608-785-6267
Mailing Address - Fax:
Practice Address - Street 1:1407 ST. ANDREW ST.
Practice Address - Street 2:
Practice Address - City:LA CROSSE
Practice Address - State:WI
Practice Address - Zip Code:54603
Practice Address - Country:US
Practice Address - Phone:608-785-6267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI157949-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse