Provider Demographics
NPI:1619160827
Name:LANDRY, VICKI L (1ST ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:VICKI
Middle Name:L
Last Name:LANDRY
Suffix:
Gender:F
Credentials:1ST ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6049 JADE AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ARTHUR
Mailing Address - State:TX
Mailing Address - Zip Code:77640-1132
Mailing Address - Country:US
Mailing Address - Phone:409-736-3584
Mailing Address - Fax:
Practice Address - Street 1:5500 39TH ST
Practice Address - Street 2:
Practice Address - City:GROVES
Practice Address - State:TX
Practice Address - Zip Code:77619-2905
Practice Address - Country:US
Practice Address - Phone:409-962-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-21
Last Update Date:2007-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX06-246246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist