Provider Demographics
NPI:1710006101
Name:FAIREY, VICKY LYNNE (RN,C)
Entity Type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:LYNNE
Last Name:FAIREY
Suffix:
Gender:F
Credentials:RN,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:943 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:CARUTHERSVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63830-1757
Mailing Address - Country:US
Mailing Address - Phone:573-333-2894
Mailing Address - Fax:573-333-2607
Practice Address - Street 1:HIGHWAY J NORTH BOX 441
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851
Practice Address - Country:US
Practice Address - Phone:573-359-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO142179163WA0400X, 163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
Not Answered163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health