Provider Demographics
NPI:1225404841
Name:KIVLAN, VICTORIA (AUD)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:
Last Name:KIVLAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 NORTH STATE STREET
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-815-6064
Mailing Address - Fax:601-984-5085
Practice Address - Street 1:2500 NORTH STATE STREET
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216
Practice Address - Country:US
Practice Address - Phone:601-815-6064
Practice Address - Fax:601-984-5085
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX80755231H00000X
MSA4056231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03232225Medicaid
MS468633YJ5DMedicare PIN