Provider Demographics
NPI:1790475721
Name:NICKERSON, VICTORIA TAITE
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:TAITE
Last Name:NICKERSON
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 1:8414 NAAB ROAD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46260
Mailing Address - Country:US
Mailing Address - Phone:317-338-7510
Mailing Address - Fax:317-338-7783
Practice Address - Street 1:8414 NAAB ROAD
Practice Address - Street 2:SUITE 215
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260
Practice Address - Country:US
Practice Address - Phone:317-338-7510
Practice Address - Fax:317-338-7783
Is Sole Proprietor?:No
Enumeration Date:2023-05-12
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program