Healthcare Provider Details

I. General information

NPI: 1760460968
Provider Name (Legal Business Name): MARTA VICKERS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 01/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1434 PORTER ST
FORT DETRICK MD
21702-9210
US

IV. Provider business mailing address

1434 PORTER ST
FORT DETRICK MD
21702-9254
US

V. Phone/Fax

Practice location:
  • Phone: 301-619-4820
  • Fax:
Mailing address:
  • Phone: 301-619-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR13197
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: