Healthcare Provider Details

I. General information

NPI: 1467129049
Provider Name (Legal Business Name): VICTOR IAN RODIONOFF NP, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 21ST AVE APT 6
SAN FRANCISCO CA
94121-2142
US

IV. Provider business mailing address

229 21ST AVE APT 6
SAN FRANCISCO CA
94121-2142
US

V. Phone/Fax

Practice location:
  • Phone: 650-703-8905
  • Fax:
Mailing address:
  • Phone: 650-703-8905
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number95166305
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95021917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: