Healthcare Provider Details

I. General information

NPI: 1295476109
Provider Name (Legal Business Name): VICTORIA MOMPOINT CLD, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 04/05/2022
Certification Date: 04/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3980 SW 24TH AVE
GAINESVILLE FL
32607-4454
US

IV. Provider business mailing address

3960 SW 24TH AVE APT 102
GAINESVILLE FL
32607-4473
US

V. Phone/Fax

Practice location:
  • Phone: 352-663-2184
  • Fax:
Mailing address:
  • Phone: 352-663-2184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number881583935
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: