MEDICARE: MS. VICKI SIEDLACK N.P

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	363L00000X	Nurse Practitioner	ARNP3099632	FL

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1689682262
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. VICKI SIEDLACK N.P

Provider Business Mailing Address
First Line	:	14050 NW 14TH ST
Second Line	:	SUITE 190
City	:	SUNRISE
State	:	FL
Zip	:	33323-2865
Country	:	US
Telephone Number	:	800-424-3672
Fax Number	:	954-377-3042

Provider Business Practice Location Address
First Line	:	4016 SUN CITY CENTER BLVD
Second Line	:
City	:	SUN CITY CENTER
State	:	FL
Zip	:	33573-5256
Country	:	US
Telephone Number	:	813-634-3301
Fax Number	:

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

Provider Enumeration Date	:	08/03/2006
Last Update Date	:	07/08/2007

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