Provider Demographics
NPI:1811642663
Name:WILSON, VICKIE RENAE
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:RENAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 RAINTREE DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-6225
Mailing Address - Country:US
Mailing Address - Phone:214-558-4164
Mailing Address - Fax:
Practice Address - Street 1:6045 RAINTREE DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-6225
Practice Address - Country:US
Practice Address - Phone:214-558-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-18
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246R00000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Pathology