Provider Demographics
NPI:1790903979
Name:NISSLEY, VICKIE LEE (RN)
Entity Type:Individual
Prefix:MRS
First Name:VICKIE
Middle Name:LEE
Last Name:NISSLEY
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8070 MAYWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:MD
Mailing Address - Zip Code:21122-3713
Mailing Address - Country:US
Mailing Address - Phone:144-363-1506
Mailing Address - Fax:
Practice Address - Street 1:140 STEPNEY LN
Practice Address - Street 2:
Practice Address - City:EDGEWATER
Practice Address - State:MD
Practice Address - Zip Code:21037-2801
Practice Address - Country:US
Practice Address - Phone:141-022-2103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR171939163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4598Medicaid