Provider Demographics
NPI:1134252778
Name:CARMACK HALL, VICKI J (LPN)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:J
Last Name:CARMACK HALL
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 1:1303 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45434-8029
Mailing Address - Country:US
Mailing Address - Phone:937-974-0411
Mailing Address - Fax:937-427-2989
Practice Address - Street 1:1303 WINDSOR DR
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45434-8029
Practice Address - Country:US
Practice Address - Phone:937-974-0411
Practice Address - Fax:937-427-2989
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2016-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.084143164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2108203OtherINDEPENDENT PROVIDER
OH311752863OtherTAX ID