MEDICARE: GINA A VICTOME REGISTER NURSE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	RN9346631	FL

General Provider Information

NPI Number	:	1053954495
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA A VICTOME REGISTER NURSE

Provider Business Mailing Address
First Line	:	4431 WESTROADS DR
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33407-1207
Country	:	US
Telephone Number	:	561-469-1959
Fax Number	:	561-584-7510

Provider Business Practice Location Address
First Line	:	4431 WESTROADS DR
Second Line	:
City	:	RIVIERA BEACH
State	:	FL
Zip	:	33407-1207
Country	:	US
Telephone Number	:	561-469-1959
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/17/2019
Last Update Date	:	06/24/2020

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