Healthcare Provider Details

I. General information

NPI: 1538600614
Provider Name (Legal Business Name): VICTORIA BROGDON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2017
Last Update Date: 03/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 HOYT ST SW
WARREN OH
44485-3847
US

IV. Provider business mailing address

805 HOYT ST SW
WARREN OH
44485-3847
US

V. Phone/Fax

Practice location:
  • Phone: 330-984-1593
  • Fax:
Mailing address:
  • Phone: 330-984-1593
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number376873231097
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: