Provider Demographics
NPI:1881907731
Name:VICKERS, DONNA (NP)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:VICKERS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MIMOSA DRIVE
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792
Mailing Address - Country:US
Mailing Address - Phone:229-228-2834
Mailing Address - Fax:229-551-8799
Practice Address - Street 1:100 MIMOSA DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6676
Practice Address - Country:US
Practice Address - Phone:229-228-2834
Practice Address - Fax:229-551-8799
Is Sole Proprietor?:No
Enumeration Date:2010-07-21
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN122291363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN122291OtherSTATE LICENSE