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Individual

IVY VICKERS

Active
Sole proprietor
No

Provider details

NPI number
Gender
F

Contact information

Practice address
657 HEMLOCK ST, SUITE 220, MACON, GA 31201
(478) 361-6921
Mailing address
118 CHADWYCK CIR, BONAIRE, GA 31005-3167
(478) 213-6948

Taxonomy

Speciality
Code
Description
License number
State
363LF0000X
Family Nurse Practitioner
Primary
RN215789
GA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
05
812782599
GA
Enumeration date
09/22/2016
Last updated
09/22/2016
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