Healthcare Provider Details

I. General information

NPI: 1528272929
Provider Name (Legal Business Name): VICKI RISKO SMITH APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2007
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1223 GATEWAY DR STE 1A
MELBOURNE FL
32901-2607
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-6712
  • Fax: 321-409-6812
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9356774
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: