Provider Demographics
NPI:1902376189
Name:DYAL, VICKIE
Entity Type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:DYAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16653 NW 167TH PL
Mailing Address - Street 2:
Mailing Address - City:ALACHUA
Mailing Address - State:FL
Mailing Address - Zip Code:32615-8908
Mailing Address - Country:US
Mailing Address - Phone:352-316-3631
Mailing Address - Fax:
Practice Address - Street 1:14804 NW 140TH ST
Practice Address - Street 2:
Practice Address - City:ALACHUA
Practice Address - State:FL
Practice Address - Zip Code:32615-6276
Practice Address - Country:US
Practice Address - Phone:386-462-0020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP3996171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist