Provider Demographics
NPI:1740685528
Name:WHACK, VIVIAN MICHELE (LPN)
Entity type:Individual
Prefix:MS
First Name:VIVIAN
Middle Name:MICHELE
Last Name:WHACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 LINDA DR
Mailing Address - Street 2:APT 5
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-2744
Mailing Address - Country:US
Mailing Address - Phone:716-400-5357
Mailing Address - Fax:716-881-6247
Practice Address - Street 1:64 LINDA DR
Practice Address - Street 2:APT 5
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-2744
Practice Address - Country:US
Practice Address - Phone:716-400-5357
Practice Address - Fax:716-881-6247
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY209444-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse