1275159733 NPI number — VICTORIA SUSAN WAICUS ARNP

Table of content: VICTORIA SUSAN WAICUS ARNP (NPI 1275159733)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275159733 NPI number — VICTORIA SUSAN WAICUS ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WAICUS
Provider First Name:
VICTORIA
Provider Middle Name:
SUSAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275159733
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
303 N CLYDE MORRIS BLVD
Provider Second Line Business Mailing Address:
CREDENTIAL SERVICES
Provider Business Mailing Address City Name:
DAYTONA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32114-2709
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-425-2285
Provider Business Mailing Address Fax Number:
386-425-7522

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 SILVER CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDGEWATER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32141-5114
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-690-6923
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/21/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  APRN11007654 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 108173700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com