Provider Demographics
NPI:1063478337
Name:BALLANTYNE, VICTORIA (CRNA)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1789
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24008-1789
Mailing Address - Country:US
Mailing Address - Phone:540-855-5139
Mailing Address - Fax:
Practice Address - Street 1:438 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-3610
Practice Address - Country:US
Practice Address - Phone:540-378-5276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024-055940367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8934894Medicaid
VA8934894Medicaid
VA006355R93Medicare PIN
VA8935068Medicaid
VA430001684Medicare PIN
VAR36782Medicare UPIN
VA8934916Medicaid
VA8934924Medicaid