Provider Demographics
NPI:1144740358
Name:BLANK, VICTORIA A (CGC)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:BLANK
Suffix:
Gender:F
Credentials:CGC
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:A
Other - Last Name:VAN VREEDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CGC
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-252-7458
Mailing Address - Fax:
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-252-7458
Practice Address - Fax:608-258-6772
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1144740358Medicaid