Provider Demographics
NPI:1255311304
Name:LATESSA, VICTORIA ROSE (NP)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:ROSE
Last Name:LATESSA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 ELLIOTT PL
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-1964
Mailing Address - Country:US
Mailing Address - Phone:201-460-1327
Mailing Address - Fax:
Practice Address - Street 1:130 E 77TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-1851
Practice Address - Country:US
Practice Address - Phone:212-434-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY503782-1363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02075652Medicaid