Provider Demographics
NPI:1730288598
Name:HUFFMAN, VICKI LYNN (PAC)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:LYNN
Last Name:HUFFMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MS
Other - First Name:VICKI
Other - Middle Name:LYNN
Other - Last Name:WARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1841 SEVENTH NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504
Mailing Address - Country:US
Mailing Address - Phone:616-453-1004
Mailing Address - Fax:
Practice Address - Street 1:436 44TH ST
Practice Address - Street 2:STE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548
Practice Address - Country:US
Practice Address - Phone:616-531-9750
Practice Address - Fax:616-531-9710
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001973363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI1504023Medicare UPIN
MIMI1504Medicare PIN
MIMI1503023Medicare UPIN
MIMI1503Medicare PIN