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General NPI Number Information
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NPI Number | 1205559812
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Entity Type | Organization
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Legal Business Name | VICTORY FAMILY WELLNESS LLC
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Dates
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Enumeration Date | 09/20/2022
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Last Update Date | 09/20/2022
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Provider Practice Location Address
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Address Line | 1812 QUENTIN RD STE M2
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City | BROOKLYN
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State | NY
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Zip | 11229-1336
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Country | US
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Telephone | 347-443-3707
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Fax | 917-791-9110
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Provider Business Mailing Address
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Address Line | 1812 QUENTIN RD STE M2
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City | BROOKLYN
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State | NY
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Zip | 11229-1336
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Country | US
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Telephone | 347-443-3707
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Fax | 917-791-9110
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Authorized Official
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Title or Position | OWNER
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Name | LARISSA JEROMINOW
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Credential | AGPCNP
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Telephone | 347-443-3707
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State |
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