Provider Demographics
NPI:1033616149
Name:FENTON, VICTORIA LYNN
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LYNN
Last Name:FENTON
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 1:1551 GANTS CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744-6459
Mailing Address - Country:US
Mailing Address - Phone:330-843-3722
Mailing Address - Fax:866-936-2963
Practice Address - Street 1:5749 WESTGATE DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-5040
Practice Address - Country:US
Practice Address - Phone:407-362-9306
Practice Address - Fax:866-936-2963
Is Sole Proprietor?:No
Enumeration Date:2018-04-06
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator