MEDICARE: MRS. CAROL ANN VIKSE R.N.

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	163W00000X	Registered Nurse	409837-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	409837-1	OTHER	NY	RN LICENSE

General Provider Information

NPI Number	:	1922372994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CAROL ANN VIKSE R.N.

Provider Business Mailing Address
First Line	:	330 DURANT AVE
Second Line	:	P.S. 53R
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-3030
Country	:	US
Telephone Number	:	718-980-0555
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 DURANT AVE
Second Line	:	P.S. 53R
City	:	STATEN ISLAND
State	:	NY
Zip	:	10308-3030
Country	:	US
Telephone Number	:	718-980-0555
Fax Number	:

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

Provider Enumeration Date	:	03/08/2012
Last Update Date	:	03/08/2012

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