Healthcare Provider Details

I. General information

NPI: 1033580394
Provider Name (Legal Business Name): VICKY ST JOHN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2015
Last Update Date: 10/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W HOUSTON ST
JASPER TX
75951-4013
US

IV. Provider business mailing address

315 W HOUSTON ST
JASPER TX
75951-4013
US

V. Phone/Fax

Practice location:
  • Phone: 409-384-3430
  • Fax: 409-383-1054
Mailing address:
  • Phone: 409-384-3430
  • Fax: 409-383-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP129324
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: