Provider Demographics
NPI:1669249207
Name:VICK, TIYANA (LP61343142)
Entity type:Individual
Prefix:
First Name:TIYANA
Middle Name:
Last Name:VICK
Suffix:
Gender:F
Credentials:LP61343142
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 16TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98112-5226
Mailing Address - Country:US
Mailing Address - Phone:206-326-4545
Mailing Address - Fax:206-326-4555
Practice Address - Street 1:201 16TH AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98112-5226
Practice Address - Country:US
Practice Address - Phone:206-326-4545
Practice Address - Fax:206-326-4555
Is Sole Proprietor?:No
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALP61343142164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse