=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093080681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAREN VICKERY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2012
-----------------------------------------------------
Last Update Date | 03/14/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5535 S WILLIAMSON BLVD STE 774
-----------------------------------------------------
City | PORT ORANGE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32128-8311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-330-7711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 507 NEW MEXICO AVE
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 87701-3238
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | A-340
-----------------------------------------------------
License Number State | NM
-----------------------------------------------------