MEDICARE: VICKI LYNN ENDRES CNM

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	367A00000X	Advanced Practice Midwife	23563	WV
2	367A00000X	Advanced Practice Midwife	116	WV
3	367A00000X	Advanced Practice Midwife	9360329	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7498050	OTHER	WV	AETNA
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	001721059	OTHER	WV	MS BCBS

General Provider Information

NPI Number	:	1588643266
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKI LYNN ENDRES CNM

Provider Business Mailing Address
First Line	:	120 E BLUE WATER EDGE DR
Second Line	:
City	:	EUSTIS
State	:	FL
Zip	:	32736-2252
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6101 LAKE ELLENOR DR
Second Line	:
City	:	ORLANDO
State	:	FL
Zip	:	32809-4616
Country	:	US
Telephone Number	:	407-858-1400
Fax Number	:	407-858-5519

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

Provider Enumeration Date	:	01/11/2006
Last Update Date	:	02/26/2018

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