Provider Demographics
NPI:1902043300
Name:STATUM, VETRES OREATHER (LPN)
Entity Type:Individual
Prefix:MS
First Name:VETRES
Middle Name:OREATHER
Last Name:STATUM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 JOEL DR
Mailing Address - Street 2:YOUNG EAGLE CLINIC
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5318
Mailing Address - Country:US
Mailing Address - Phone:270-798-8258
Mailing Address - Fax:270-956-0444
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:YOUNG EAGLE CLINIC
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-798-8258
Practice Address - Fax:270-956-0444
Is Sole Proprietor?:No
Enumeration Date:2009-01-07
Last Update Date:2009-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000068878164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0000068878OtherNURSING LICENSE