Provider Demographics
NPI:1043966641
Name:MCMILLAN, VICKI
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:
Last Name:MCMILLAN
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 1:7487 HIGHWAY 613
Mailing Address - Street 2:
Mailing Address - City:MOSS POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39563
Mailing Address - Country:US
Mailing Address - Phone:228-366-4954
Mailing Address - Fax:228-285-0445
Practice Address - Street 1:7487 HIGHWAY 613
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563
Practice Address - Country:US
Practice Address - Phone:228-366-4954
Practice Address - Fax:228-285-0445
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X
MS1312387374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide