Provider Demographics
NPI:1760961114
Name:VICK, LETTI
Entity Type:Individual
Prefix:
First Name:LETTI
Middle Name:
Last Name:VICK
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 1:4636 COUNTY ROAD 112 N
Mailing Address - Street 2:
Mailing Address - City:OVERTON
Mailing Address - State:TX
Mailing Address - Zip Code:75684-5103
Mailing Address - Country:US
Mailing Address - Phone:903-722-3055
Mailing Address - Fax:
Practice Address - Street 1:4636 COUNTY ROAD 112 N
Practice Address - Street 2:
Practice Address - City:OVERTON
Practice Address - State:TX
Practice Address - Zip Code:75684-5103
Practice Address - Country:US
Practice Address - Phone:903-722-3055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-07
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX724917163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health