Provider Demographics
NPI:1093178428
Name:VICTORY NP IN PSYCHIATRY, PC
Entity Type:Organization
Organization Name:VICTORY NP IN PSYCHIATRY, PC
Other - Org Name:N/A
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GODWIN
Authorized Official - Middle Name:MCMUKORO
Authorized Official - Last Name:OKPOMO
Authorized Official - Suffix:SR
Authorized Official - Credentials:NURSE PRACTITIONER
Authorized Official - Phone:646-384-0252
Mailing Address - Street 1:2962 WICKHAM AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10469-3324
Mailing Address - Country:US
Mailing Address - Phone:646-384-0252
Mailing Address - Fax:
Practice Address - Street 1:2962 WICKHAM AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3324
Practice Address - Country:US
Practice Address - Phone:646-384-0252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:N/A
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-02
Last Update Date:2016-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY401152363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1043696750OtherNPI NUMBER