Healthcare Provider Details

I. General information

NPI: 1588643266
Provider Name (Legal Business Name): VICKI LYNN ENDRES CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2006
Last Update Date: 02/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 LAKE ELLENOR DR
ORLANDO FL
32809-4616
US

IV. Provider business mailing address

120 E BLUE WATER EDGE DR
EUSTIS FL
32736-2252
US

V. Phone/Fax

Practice location:
  • Phone: 407-858-1400
  • Fax: 407-858-5519
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number23563
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number116
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number9360329
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: