Provider Demographics
NPI:1013562966
Name:MOELLER, VICTORIA ASHLEY
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ASHLEY
Last Name:MOELLER
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 1:3201 128TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-7536
Mailing Address - Country:US
Mailing Address - Phone:763-447-9422
Mailing Address - Fax:
Practice Address - Street 1:3201 128TH AVE NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-7536
Practice Address - Country:US
Practice Address - Phone:763-447-9422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-07
Last Update Date:2019-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2475556163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse