Healthcare Provider Details

I. General information

NPI: 1508301649
Provider Name (Legal Business Name): MA VICTORIA AQUINO KHERA AGPCNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MA VICTORIA VILLANUEVA AQUINO

II. Dates (important events)

Enumeration Date: 12/28/2016
Last Update Date: 12/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2467 GOLDEN CAMP RD
AUGUSTA GA
30906-5515
US

IV. Provider business mailing address

608 BURGAMY PASS
GROVETOWN GA
30813-5855
US

V. Phone/Fax

Practice location:
  • Phone: 706-790-4440
  • Fax:
Mailing address:
  • Phone: 714-624-5631
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number243278
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number243278
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number243278
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: