MEDICARE: MISS ASHLEY CATHERINE VICKNAIR CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	691127	TX

General Provider Information

NPI Number	:	1083924534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ASHLEY CATHERINE VICKNAIR CPNP

Provider Business Mailing Address
First Line	:	2601 BOLTON ST
Second Line	:
City	:	AUSTIN
State	:	TX
Zip	:	78748-3929
Country	:	US
Telephone Number	:	512-797-7568
Fax Number	:

Provider Business Practice Location Address
First Line	:	180 JOE WIMBERLEY BLVD STE 102
Second Line	:
City	:	WIMBERLEY
State	:	TX
Zip	:	78676-6083
Country	:	US
Telephone Number	:	512-847-7700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2010
Last Update Date	:	10/18/2010

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