=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790227130
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICKI LYNNE DISCON CSFA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/16/2016
-----------------------------------------------------
Last Update Date | 11/16/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18100 WEST RD APT. 910
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77095-3768
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-977-9109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18100 WEST ROAD APT. 910
-----------------------------------------------------
City | HOUSTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-977-9109
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246ZC0007X
-----------------------------------------------------
Taxonomy Name | Surgical Assistant
-----------------------------------------------------
License Number | 154792
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------