Provider Demographics
NPI:1730730854
Name:WHITE, VICKLYN DENISE
Entity type:Individual
Prefix:
First Name:VICKLYN
Middle Name:DENISE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5075 AL HIGHWAY 87
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-3442
Mailing Address - Country:US
Mailing Address - Phone:334-372-3125
Mailing Address - Fax:
Practice Address - Street 1:5075 AL HIGHWAY 87
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36079-3442
Practice Address - Country:US
Practice Address - Phone:334-372-3125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider