Healthcare Provider Details

I. General information

NPI: 1609645191
Provider Name (Legal Business Name): VICTORIA GLADDEN RAIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/26/2023
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73-5618 MAIAU ST STE A204
KAILUA KONA HI
96740-2634
US

IV. Provider business mailing address

PO BOX 13834
TALLAHASSEE FL
32317-3834
US

V. Phone/Fax

Practice location:
  • Phone: 808-329-1146
  • Fax: 808-329-1120
Mailing address:
  • Phone: 850-205-6232
  • Fax: 855-975-0615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9118307
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: