MEDICARE: STEPHANIE A VICTORIA APRN

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	363L00000X	Nurse Practitioner	11003122	FL

General Provider Information

NPI Number	:	1336792779
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE A VICTORIA APRN

Provider Business Mailing Address
First Line	:	6086 SPRING ISLES BLVD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6086 SPRING ISLES BLVD
Second Line	:
City	:	LAKE WORTH
State	:	FL
Zip	:	33463-7906
Country	:	US
Telephone Number	:	561-386-4925
Fax Number	:

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

Provider Enumeration Date	:	07/23/2019
Last Update Date	:	07/23/2019

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