Provider Demographics
NPI:1518503028
Name:VICKERS, KAYLEE SUE (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:SUE
Last Name:VICKERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4513 N 2ND DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-2912
Mailing Address - Country:US
Mailing Address - Phone:615-419-4797
Mailing Address - Fax:
Practice Address - Street 1:4513 N 2ND DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-2912
Practice Address - Country:US
Practice Address - Phone:615-419-4797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-19
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA14842363A00000X
AZ7675363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant