Provider Demographics
NPI:1245711357
Name:VICKERY, STEPHANIE KAYE (PA-C)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:KAYE
Last Name:VICKERY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:1155 MILL ST MS M14
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-1576
Mailing Address - Country:US
Mailing Address - Phone:775-982-5262
Mailing Address - Fax:775-982-4196
Practice Address - Street 1:3595 US HIGHWAY 50
Practice Address - Street 2:
Practice Address - City:SILVER SPRINGS
Practice Address - State:NV
Practice Address - Zip Code:89429-9613
Practice Address - Country:US
Practice Address - Phone:775-577-2117
Practice Address - Fax:775-577-2769
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NVPA2265363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV14632500OtherCAQH ID
NVPA2265OtherPA NEVADA LIC