=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003449596
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKI LYNN AHO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/13/2020
-----------------------------------------------------
Last Update Date | 09/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5471 W WATERFORD LN
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54913-8510
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-731-7445
-----------------------------------------------------
Fax | 920-731-7490
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5337 W GRANDE MARKET DR
-----------------------------------------------------
City | APPLETON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54913-8442
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-731-7445
-----------------------------------------------------
Fax | 920-404-2351
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Registered Nurse
-----------------------------------------------------
License Number | 127957-30
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------