Healthcare Provider Details

I. General information

NPI: 1336325802
Provider Name (Legal Business Name): MS. VICKI LOU STORK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2008
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

311 S CLARK ST
CARROLL IA
51401-3038
US

IV. Provider business mailing address

131 W 3RD ST.
GLIDDEN IA
51443
US

V. Phone/Fax

Practice location:
  • Phone: 712-794-0826
  • Fax:
Mailing address:
  • Phone: 712-830-2511
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number079618
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: