Healthcare Provider Details

I. General information

NPI: 1750875902
Provider Name (Legal Business Name): VICKI LYNN MADDOX
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 06/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2965 E 109TH AVE
NORTHGLENN CO
80233-5475
US

IV. Provider business mailing address

5517 GABRIEL DR
LOVELAND CO
80538-1653
US

V. Phone/Fax

Practice location:
  • Phone: 303-980-0015
  • Fax:
Mailing address:
  • Phone: 970-776-9066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number0098071
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: