Healthcare Provider Details

I. General information

NPI: 1275002701
Provider Name (Legal Business Name): VICTORIA PRINCESS MATTHEWS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

176 W MOUND RD
DECATUR IL
62526-1964
US

IV. Provider business mailing address

12040 RAYMOND CT
HUNTLEY IL
60142-8069
US

V. Phone/Fax

Practice location:
  • Phone: 217-875-0163
  • Fax:
Mailing address:
  • Phone: 847-515-1505
  • Fax: 847-515-1503

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.381119
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.017759
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209017759
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: