Provider Demographics
NPI:1275129611
Name:ANDERSON, VICTORIA WAYNE
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:WAYNE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2847 7TH ST W APT 113
Mailing Address - Street 2:
Mailing Address - City:WEST FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58078-6926
Mailing Address - Country:US
Mailing Address - Phone:320-293-6253
Mailing Address - Fax:
Practice Address - Street 1:2847 7TH ST W APT 113
Practice Address - Street 2:
Practice Address - City:WEST FARGO
Practice Address - State:ND
Practice Address - Zip Code:58078-6926
Practice Address - Country:US
Practice Address - Phone:320-293-6253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-20
Last Update Date:2020-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1480809374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1480809Medicaid