Provider Demographics
NPI:1700995719
Name:GOULD-KLING, VICKI JO (RN MSN ACNP-BC)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:JO
Last Name:GOULD-KLING
Suffix:
Gender:F
Credentials:RN MSN ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-3555
Mailing Address - Country:US
Mailing Address - Phone:810-982-1111
Mailing Address - Fax:810-982-8848
Practice Address - Street 1:1216 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-3555
Practice Address - Country:US
Practice Address - Phone:810-982-1111
Practice Address - Fax:810-982-8848
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704134425363L00000X, 163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1700995719Medicaid
P42381Medicare UPIN
MIMI5892Medicare PIN
MI1700995719Medicaid