Provider Demographics
NPI:1750922233
Name:CHACON, VICKI GRIGG (FNP-C)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:GRIGG
Last Name:CHACON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 48TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-5452
Mailing Address - Country:US
Mailing Address - Phone:704-300-5473
Mailing Address - Fax:
Practice Address - Street 1:1201 48TH AVE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5452
Practice Address - Country:US
Practice Address - Phone:843-450-4429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-04
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23522363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner