Provider Demographics
NPI:1588643266
Name:ENDRES, VICKI LYNN (CNM)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:ENDRES
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 E BLUE WATER EDGE DR
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32736-2252
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6101 LAKE ELLENOR DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32809-4616
Practice Address - Country:US
Practice Address - Phone:407-858-1400
Practice Address - Fax:407-858-5519
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-11
Last Update Date:2018-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23563367A00000X
WV116367A00000X
FL9360329367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7498050OtherAETNA
WV9450012000Medicaid
WV001721059OtherMS BCBS
WVNM01612Medicare PIN
WV7498050OtherAETNA
WVNM03693Medicare PIN
WVNM03692Medicare PIN
WV9450012000Medicaid
WVNM03695Medicare PIN
WVNM03694Medicare PIN
WVQ41937AMedicare PIN
WVNM01614Medicare PIN
WVNM01613Medicare PIN
WV001721059OtherMS BCBS