MEDICARE: VICTOIRE WAY OULATTA

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	164W00000X	Licensed Practical Nurse	4703129246	MI

General Provider Information

NPI Number	:	1235098112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTOIRE WAY OULATTA

Provider Business Mailing Address
First Line	:	6221 JOAQUIN HILLS CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-4825
Country	:	US
Telephone Number	:	313-352-8074
Fax Number	:

Provider Business Practice Location Address
First Line	:	6221 JOAQUIN HILLS CT
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-4825
Country	:	US
Telephone Number	:	313-352-8074
Fax Number	:

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

Provider Enumeration Date	:	01/17/2026
Last Update Date	:	01/17/2026

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Directions to “ VICTOIRE WAY OULATTA ” Practice Location

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