Provider Demographics
NPI:1982007431
Name:VICKREY, STEWART (APRN)
Entity Type:Individual
Prefix:
First Name:STEWART
Middle Name:
Last Name:VICKREY
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT STERLING
Mailing Address - State:KY
Mailing Address - Zip Code:40353-1348
Mailing Address - Country:US
Mailing Address - Phone:859-404-7686
Mailing Address - Fax:859-274-4459
Practice Address - Street 1:225 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40391-7676
Practice Address - Country:US
Practice Address - Phone:859-737-6494
Practice Address - Fax:859-737-6642
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-29
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3008775363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100352370Medicaid