Healthcare Provider Details

I. General information

NPI: 1487545414
Provider Name (Legal Business Name): VICTORIA CANNON D'AQUIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20474 OLD SCENIC HWY
ZACHARY LA
70791-7365
US

IV. Provider business mailing address

1305 VINTAGE DR
KENNER LA
70065-2045
US

V. Phone/Fax

Practice location:
  • Phone: 225-654-1124
  • Fax: 225-654-7079
Mailing address:
  • Phone: 504-344-4690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: