Provider Demographics
NPI:1134408644
Name:VACLAVIK, IDA TRICE (NP)
Entity type:Individual
Prefix:MRS
First Name:IDA
Middle Name:TRICE
Last Name:VACLAVIK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:IDA
Other - Middle Name:SAWYER
Other - Last Name:TRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:601 WATKINS CENTRE PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:VA
Mailing Address - Zip Code:23114-0002
Mailing Address - Country:US
Mailing Address - Phone:804-594-3130
Mailing Address - Fax:804-423-6517
Practice Address - Street 1:601 WATKINS CENTRE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:MIDLOTHIAN
Practice Address - State:VA
Practice Address - Zip Code:23114-0002
Practice Address - Country:US
Practice Address - Phone:804-594-3130
Practice Address - Fax:804-423-6517
Is Sole Proprietor?:No
Enumeration Date:2011-08-15
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1008705363LF0000X
VA0024172575363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09633OtherGROUP PTAN