Healthcare Provider Details

I. General information

NPI: 1881064137
Provider Name (Legal Business Name): VICKY DEUBOUE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 01/28/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2088 BRONCO LN
KELLER TX
76248-3139
US

IV. Provider business mailing address

11023 PLUMWOOD CIR
HAGERSTOWN MD
21742-4017
US

V. Phone/Fax

Practice location:
  • Phone: 862-241-0137
  • Fax:
Mailing address:
  • Phone: 469-537-5421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAC002867
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP128344
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAC002867
License Number StateMD
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP128344
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number106938
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: