Provider Demographics
NPI:1114227964
Name:VICTOR, KATHLEEN ANN (RN, MSN, CRNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ANN
Last Name:VICTOR
Suffix:
Gender:F
Credentials:RN, MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1726 SOUTH BROAD STREET
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19145-2300
Mailing Address - Country:US
Mailing Address - Phone:215-463-5009
Mailing Address - Fax:
Practice Address - Street 1:1726 SOUTH BROAD STREET
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2300
Practice Address - Country:US
Practice Address - Phone:215-463-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NN11172100363L00000X, 363LG0600X
PASP005334H363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner