Provider Demographics
NPI:1013083211
Name:VICKERY, PAULA (APRN)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:VICKERY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1635 ONEAWA PL
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-5590
Mailing Address - Country:US
Mailing Address - Phone:808-959-8785
Mailing Address - Fax:
Practice Address - Street 1:1251 KILAUEA AVE STE 190C
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-4293
Practice Address - Country:US
Practice Address - Phone:808-961-1000
Practice Address - Fax:808-961-1000
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN - 40545163WP0809X
HIAPRN - 742363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI0000247171OtherHMSA
HI0000551798Medicaid
HI0000247171OtherHMSA
HI0000551798Medicaid