Provider Demographics
NPI:1699024125
Name:VICKERY, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:VICKERY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 BLOOMFIELD AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06117-1500
Mailing Address - Country:US
Mailing Address - Phone:860-236-1927
Mailing Address - Fax:
Practice Address - Street 1:333 BLOOMFIELD AVE
Practice Address - Street 2:SUITE A
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06117-1500
Practice Address - Country:US
Practice Address - Phone:860-236-1927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program