Provider Demographics
NPI:1104041474
Name:LANDIS, VICTORIA RENEE (RN, BSN)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RENEE
Last Name:LANDIS
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6015 ALTA LOMA PL
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-5839
Mailing Address - Country:US
Mailing Address - Phone:916-955-0706
Mailing Address - Fax:
Practice Address - Street 1:1515 VALDORA ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-6346
Practice Address - Country:US
Practice Address - Phone:530-400-9752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA664459163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARVN003840Medicare ID - Type Unspecified