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General NPI Number Information
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NPI Number | 1548645021
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Entity Type | Individual
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Provider Name | JELISA VICK AG-ACNP
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Gender | Female
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Dates
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Enumeration Date | 07/24/2015
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Last Update Date | 08/22/2023
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Provider Practice Location Address
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Address Line | 2211 LOMAS BLVD NE TRAUMA/SURGICAL INTENSIVE CARE UNIT
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City | ALBUQUERQUE
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State | NM
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Zip | 87106
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Country | US
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Telephone | 505-272-2721
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 967
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City | FLAGSTAFF
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State | AZ
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Zip | 86002-0967
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Country | US
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Telephone | 928-773-0003
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Fax | 928-773-1170
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | AP8668
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License Number State | AZ
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Taxonomy #2
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Taxonomy Code | 363LA2100X
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Taxonomy Name | Acute Care Nurse Practitioner
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License Number | CNP-02725
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License Number State | NM
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