Provider Demographics
NPI:1730155060
Name:HARRELL, VICKIE N (MD)
Entity type:Individual
Prefix:DR
First Name:VICKIE
Middle Name:N
Last Name:HARRELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1330
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444
Mailing Address - Country:US
Mailing Address - Phone:850-913-0018
Mailing Address - Fax:850-913-9137
Practice Address - Street 1:292 FOREST PARK CIR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4921
Practice Address - Country:US
Practice Address - Phone:850-913-0018
Practice Address - Fax:850-913-9137
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070385208D00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379777500Medicaid
FLG27751Medicare UPIN
FL379777500Medicaid