Provider Demographics
NPI:1205267945
Name:DANIEL, VICKI
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:DANIEL
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 1:1421 W MARLBORO ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67217-2435
Mailing Address - Country:US
Mailing Address - Phone:316-312-4111
Mailing Address - Fax:
Practice Address - Street 1:1421 W MARLBORO ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67217-2435
Practice Address - Country:US
Practice Address - Phone:316-312-4111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200558490AMedicaid