Provider Demographics
NPI:1790811958
Name:MCINNIS, VICKY LYNNE (PTA)
Entity Type:Individual
Prefix:MRS
First Name:VICKY
Middle Name:LYNNE
Last Name:MCINNIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 HARPER AVE
Mailing Address - Street 2:
Mailing Address - City:CAROLINA BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28428-4314
Mailing Address - Country:US
Mailing Address - Phone:910-458-8569
Mailing Address - Fax:
Practice Address - Street 1:1328 N LAKE PARK BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:CAROLINA BEACH
Practice Address - State:NC
Practice Address - Zip Code:28428-3935
Practice Address - Country:US
Practice Address - Phone:910-458-8884
Practice Address - Fax:910-458-3976
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3072225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant