Provider Demographics
NPI:1265083802
Name:ANDERSON, VICKIE (PMHNP)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2178
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-2178
Mailing Address - Country:US
Mailing Address - Phone:503-678-5626
Mailing Address - Fax:503-678-2223
Practice Address - Street 1:1846 E INNOVATION PARK DR
Practice Address - Street 2:
Practice Address - City:ORO VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:85755-1963
Practice Address - Country:US
Practice Address - Phone:520-771-0555
Practice Address - Fax:262-260-9109
Is Sole Proprietor?:No
Enumeration Date:2019-09-25
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142086363LP0808X
AZ250787363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP142086OtherNURSE PRACTITIONER