Healthcare Provider Details

I. General information

NPI: 1255194494
Provider Name (Legal Business Name): STEPHANIE LYNN VICK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2024
Last Update Date: 12/21/2025
Certification Date: 12/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 OLD REYNOLDS ST
WAYCROSS GA
31501-1036
US

IV. Provider business mailing address

1307 DAN DURAN RD
NICHOLLS GA
31554-5837
US

V. Phone/Fax

Practice location:
  • Phone: 912-283-5260
  • Fax:
Mailing address:
  • Phone: 912-327-0182
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN209399
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: