Healthcare Provider Details

I. General information

NPI: 1679357578
Provider Name (Legal Business Name): VICKI WALTRIP RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 RICHMOND RD
DEXTER NM
88230-9520
US

IV. Provider business mailing address

9 RICHMOND RD
DEXTER NM
88230-9520
US

V. Phone/Fax

Practice location:
  • Phone: 575-910-1750
  • Fax:
Mailing address:
  • Phone: 575-910-1750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberR52594
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: