Basic Information
Provider Information
NPI: 1003299561
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: VICK
FirstName: CHRISHAUNDA
MiddleName: LAKEISH
NamePrefix: MRS.
NameSuffix:  
Credential: FNP-C
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1918 YAMACRAW DR
Address2:  
City: KNIGHTDALE
State: NC
PostalCode: 275457471
CountryCode: US
TelephoneNumber: 9199236476
FaxNumber:  
Practice Location
Address1: 4680 US-177
Address2:  
City: PIKEVILLE
State: NC
PostalCode: 27863
CountryCode: US
TelephoneNumber: 9195873400
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/02/2015
LastUpdateDate: 12/14/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363LF0000X5007728NCY Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

ID Information
IDTypeStateIssuerDescription
MV355952501NCDEAOTHER


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