Provider Demographics
NPI:1770180937
Name:LUSK, VICKIE S
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:S
Last Name:LUSK
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:PO BOX 835
Mailing Address - Street 2:
Mailing Address - City:MULLENS
Mailing Address - State:WV
Mailing Address - Zip Code:25882-0835
Mailing Address - Country:US
Mailing Address - Phone:304-294-5610
Mailing Address - Fax:304-294-2040
Practice Address - Street 1:3750 MOUNTAINEER HIGHWAY
Practice Address - Street 2:
Practice Address - City:MABEN
Practice Address - State:WV
Practice Address - Zip Code:25870
Practice Address - Country:US
Practice Address - Phone:304-294-5610
Practice Address - Fax:304-294-2040
Is Sole Proprietor?:No
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant