Provider Demographics
NPI:1851474704
Name:VICKERS, LISA A (ARNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:VICKERS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 N 16TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-1381
Mailing Address - Country:US
Mailing Address - Phone:509-249-0105
Mailing Address - Fax:509-249-0035
Practice Address - Street 1:1450 N 16TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-1381
Practice Address - Country:US
Practice Address - Phone:509-249-0105
Practice Address - Fax:509-249-0035
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30007200363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9647793Medicaid
WA9647793Medicaid
WA8859657Medicare ID - Type Unspecified