Provider Demographics
NPI:1174188478
Name:VICKLAND, LYNDERA (LMT)
Entity type:Individual
Prefix:MRS
First Name:LYNDERA
Middle Name:
Last Name:VICKLAND
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 FOXWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-5210
Mailing Address - Country:US
Mailing Address - Phone:757-267-5877
Mailing Address - Fax:
Practice Address - Street 1:1248 GUNN HALL DR STE 102
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-5757
Practice Address - Country:US
Practice Address - Phone:757-637-0189
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019016556225700000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0019016556OtherVA BOARD OF NURSING DEPARTMENT OF HEALTH PROFESSIONS
VA11741888478Medicaid