Provider Demographics
NPI:1669424677
Name:VICKERS, PATRICIA (RTD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:VICKERS
Suffix:
Gender:F
Credentials:RTD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 NINTH AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104
Mailing Address - Country:US
Mailing Address - Phone:817-336-7191
Mailing Address - Fax:817-332-3172
Practice Address - Street 1:909 NINTH AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104
Practice Address - Country:US
Practice Address - Phone:817-336-7191
Practice Address - Fax:817-332-3172
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT02980133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P88453Medicare UPIN
8G4530Medicare ID - Type Unspecified