Healthcare Provider Details

I. General information

NPI: 1073123790
Provider Name (Legal Business Name): JACQUELIN N VICTORY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2020
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 STANTONSBURG RD
GREENVILLE NC
27834-2818
US

IV. Provider business mailing address

1419 DOCTOR BLAIR RD
MARSHVILLE NC
28103-9706
US

V. Phone/Fax

Practice location:
  • Phone: 252-847-4100
  • Fax:
Mailing address:
  • Phone: 704-201-4230
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number6646
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number262101
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: