Healthcare Provider Details

I. General information

NPI: 1780452045
Provider Name (Legal Business Name): KATHERINE ELIZABETH VICKERS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 11/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 N COAST HIGHWAY 101
ENCINITAS CA
92024-2047
US

IV. Provider business mailing address

726 RODEO ST
OCEANSIDE CA
92058-6881
US

V. Phone/Fax

Practice location:
  • Phone: 760-230-1888
  • Fax:
Mailing address:
  • Phone: 240-321-4622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: