=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336325802
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. VICKI LOU STORK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2008
-----------------------------------------------------
Last Update Date | 01/15/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 311 S CLARK ST
-----------------------------------------------------
City | CARROLL
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51401-3038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-794-0826
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 131 W 3RD ST.
-----------------------------------------------------
City | GLIDDEN
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 51443
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 712-830-2511
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WM0705X
-----------------------------------------------------
Taxonomy Name | Medical-Surgical Registered Nurse
-----------------------------------------------------
License Number | 079618
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------