Provider Demographics
NPI:1649215070
Name:WEATHERS, VICKIE K (CNS)
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:K
Last Name:WEATHERS
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 4TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-2912
Mailing Address - Country:US
Mailing Address - Phone:701-839-0474
Mailing Address - Fax:701-839-0713
Practice Address - Street 1:307 5TH AVE SE
Practice Address - Street 2:SUITE 502
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4784
Practice Address - Country:US
Practice Address - Phone:701-857-2199
Practice Address - Fax:701-857-2199
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR28599163W00000X
NDL9274164X00000X
ND0388003-02364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
No163W00000XNursing Service ProvidersRegistered Nurse
No164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND025500OtherBCBS OF ND PIN
ND70009Medicaid
NDP00160106OtherRR MEDICARE
NDP00659747OtherRR MEDICARE
NDP00160106OtherRR MEDICARE
ND025500OtherBCBS OF ND PIN
NDN25500Medicare ID - Type Unspecified
NDV21519Medicare UPIN