Provider Demographics
NPI:1043761117
Name:BALOGUN, VICTORIA RANTI (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RANTI
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:OLUWARANTI
Other - Last Name:BALOGUN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:14121 PARKE LONG CT STE 201
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1647
Mailing Address - Country:US
Mailing Address - Phone:864-551-5536
Mailing Address - Fax:
Practice Address - Street 1:14121 PARKE LONG COURT, SUITE 201
Practice Address - Street 2:
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151
Practice Address - Country:US
Practice Address - Phone:864-551-5536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20493363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily