Provider Demographics
NPI:1003307596
Name:VICTOR, MARIE C
Entity Type:Individual
Prefix:
First Name:MARIE
Middle Name:C
Last Name:VICTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2823 SW 82ND AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-7404
Mailing Address - Country:US
Mailing Address - Phone:954-638-0324
Mailing Address - Fax:
Practice Address - Street 1:2 HOSPITAL DR STE 101
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-6616
Practice Address - Country:US
Practice Address - Phone:413-536-8924
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-21
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9267015363LF0000X
MARN2337712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily