Healthcare Provider Details

I. General information

NPI: 1104412519
Provider Name (Legal Business Name): VICTORIA MCRAE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2020
Last Update Date: 02/24/2021
Certification Date: 12/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E MAXWELL ST STE 130
LEXINGTON KY
40508-2678
US

IV. Provider business mailing address

3156 CHELSEA DR
LEXINGTON KY
40503-2726
US

V. Phone/Fax

Practice location:
  • Phone: 859-562-0897
  • Fax:
Mailing address:
  • Phone: 973-902-7930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC267
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: