Provider Demographics
NPI:1801081740
Name:VICKERY, EDITH ANN (CRNFA)
Entity type:Individual
Prefix:MRS
First Name:EDITH
Middle Name:ANN
Last Name:VICKERY
Suffix:
Gender:F
Credentials:CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3302 BILL OWENS PKWY
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-1612
Mailing Address - Country:US
Mailing Address - Phone:903-297-2958
Mailing Address - Fax:
Practice Address - Street 1:3302 BILL OWENS PKWY
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-1612
Practice Address - Country:US
Practice Address - Phone:903-297-2958
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX548718163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant