MEDICARE: MRS. LYNDERA VICKLAND LMT

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	225700000X	Massage Therapist	0019016556	VA
2	208VP0000X	Pain Medicine Physician	0019016556	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0019016556	OTHER	VA	VA BOARD OF NURSING DEPARTMENT OF HEALTH PROFESSIONS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174188478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LYNDERA VICKLAND LMT

Provider Business Mailing Address
First Line	:	4021 FOXWOOD DR
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-5210
Country	:	US
Telephone Number	:	757-267-5877
Fax Number	:

Provider Business Practice Location Address
First Line	:	1248 GUNN HALL DR STE 102
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5757
Country	:	US
Telephone Number	:	757-637-0189
Fax Number	:

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

Provider Enumeration Date	:	05/02/2019
Last Update Date	:	05/25/2021

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