Healthcare Provider Details

I. General information

NPI: 1245725167
Provider Name (Legal Business Name): VICTORIA KAMAKEA BALLARES FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2018
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

133 BIRADAN ANAKKO
DEDEDO GU
96929-5739
US

IV. Provider business mailing address

PO BOX 8904
TAMUNING GU
96931-8904
US

V. Phone/Fax

Practice location:
  • Phone: 671-645-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRX0410
License Number StateGU
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP0183
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: