Healthcare Provider Details

I. General information

NPI: 1255895017
Provider Name (Legal Business Name): VICTORIA MANSFIELD PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VICTORIA CULLEN PA

II. Dates (important events)

Enumeration Date: 01/25/2019
Last Update Date: 04/17/2024
Certification Date: 04/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 MCINGVALE RD STE J
HERNANDO MS
38632-8696
US

IV. Provider business mailing address

6077 PRIMACY PKWY STE 140
MEMPHIS TN
38119-5754
US

V. Phone/Fax

Practice location:
  • Phone: 901-259-1600
  • Fax: 901-259-1698
Mailing address:
  • Phone: 901-725-8347
  • Fax: 901-259-7637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA00419
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3785
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00419
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3785
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: