MEDICARE: VICKI JO GOULD-KLING RN MSN ACNP-BC

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	363L00000X	Nurse Practitioner	4704134425	MI
2	163WR0006X	Registered Nurse First Assistant	4704134425	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1700995719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICKI JO GOULD-KLING RN MSN ACNP-BC

Provider Business Mailing Address
First Line	:	1216 WASHINGTON AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3555
Country	:	US
Telephone Number	:	810-982-1111
Fax Number	:	810-982-8848

Provider Business Practice Location Address
First Line	:	1216 WASHINGTON AVE
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-3555
Country	:	US
Telephone Number	:	810-982-1111
Fax Number	:	810-982-8848

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

Provider Enumeration Date	:	08/30/2006
Last Update Date	:	08/22/2016

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