Healthcare Provider Details

I. General information

NPI: 1386699262
Provider Name (Legal Business Name): VICTORIA MANIGAULT CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4050 BRIDGE VIEW DR
NORTH CHARLESTON SC
29405-8415
US

IV. Provider business mailing address

533 CARTERS GRV
CHARLESTON SC
29414-9015
US

V. Phone/Fax

Practice location:
  • Phone: 843-746-3834
  • Fax: 843-746-3814
Mailing address:
  • Phone: 843-769-6297
  • Fax: 843-746-3814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1539
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: