MEDICARE: VICKIE R GAILLARD LPN

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	164W00000X	Licensed Practical Nurse	34494-31	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124275623
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKIE R GAILLARD LPN

Provider Business Mailing Address
First Line	:	4480 N 85TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-5108
Country	:	US
Telephone Number	:	414-461-8084
Fax Number	:

Provider Business Practice Location Address
First Line	:	4480 N 85TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-5108
Country	:	US
Telephone Number	:	414-461-8084
Fax Number	:

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

Provider Enumeration Date	:	08/26/2008
Last Update Date	:	08/26/2008

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