Healthcare Provider Details

I. General information

NPI: 1780452045
Provider Name (Legal Business Name): KATHERINE ELIZABETH VICKERS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATHERINE SISLO

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2538
US

IV. Provider business mailing address

100 BREWSTER BLVD
CAMP LEJEUNE NC
28547-2538
US

V. Phone/Fax

Practice location:
  • Phone: 910-450-4357
  • Fax:
Mailing address:
  • Phone: 910-450-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number502491
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95028106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: