Provider Demographics
NPI:1801013495
Name:GERVAIS, VICKII (LM, LAC)
Entity Type:Individual
Prefix:
First Name:VICKII
Middle Name:
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:LM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5837 EL CAJON BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115
Mailing Address - Country:US
Mailing Address - Phone:619-286-2888
Mailing Address - Fax:619-286-2888
Practice Address - Street 1:5837 EL CAJON BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115
Practice Address - Country:US
Practice Address - Phone:619-286-2888
Practice Address - Fax:619-286-2888
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10927171100000X
CALM106176B00000X
CAAC10927171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No171100000XOther Service ProvidersAcupuncturist