Individual
MRS. STACEE VICKERS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
P.T.
Contact information
Practice address
318 W PIKE ST, SUITE 104, LAWRENCEVILLE, GA 30045-3234
(678) 377-2833
(678) 377-2882
Mailing address
1092 ADAH LN, LAWRENCEVILLE, GA 30043-7225
(678) 618-9022
Taxonomy
Speciality
Code
Description
License number
State
2251P0200X
Pediatric Physical Therapist
Primary
004817
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00776993D
—
GA
01
—
10037646
AMERIGROUP PROVIDER #
GA
01
—
307933
WELLCARE PROVIDER #
GA
Enumeration date
11/29/2006
Last updated
07/09/2007
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