MEDICARE: VICKIE LYNN NICKELS TRADITIONAL MIDWIFE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175M00000X	Lay Midwife

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2022-0025	OTHER	OR	OREGON HEALTH AUTHORITY MIDWIFE NUMBER

General Provider Information

NPI Number	:	1588391973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKIE LYNN NICKELS TRADITIONAL MIDWIFE

Provider Business Mailing Address
First Line	:	224 SCHOONER BAY DR
Second Line	:
City	:	BROOKINGS
State	:	OR
Zip	:	97415-9061
Country	:	US
Telephone Number	:	541-661-4652
Fax Number	:

Provider Business Practice Location Address
First Line	:	224 SCHOONER BAY DR
Second Line	:
City	:	BROOKINGS
State	:	OR
Zip	:	97415-9061
Country	:	US
Telephone Number	:	541-661-4652
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2022
Last Update Date	:	08/04/2022

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