Provider Demographics
NPI:1255363826
Name:WADE, VICKIE C (WHNP-C)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:C
Last Name:WADE
Suffix:
Gender:F
Credentials:WHNP-C
Other - Prefix:
Other - First Name:VICKIE
Other - Middle Name:C
Other - Last Name:FRAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ANP
Mailing Address - Street 1:5701 DELMAR BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-2617
Mailing Address - Country:US
Mailing Address - Phone:314-367-7848
Mailing Address - Fax:314-367-2985
Practice Address - Street 1:5701 DELMAR BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-2617
Practice Address - Country:US
Practice Address - Phone:314-367-7848
Practice Address - Fax:314-367-2985
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN095910363LW0102X
MO095910363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO423909811Medicaid
MOP11005Medicare UPIN
MO500022681Medicare PIN