Provider Demographics
NPI:1578818738
Name:LANDA, VICTORIA E
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:E
Last Name:LANDA
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 1:14 ANNAPOLIS DR
Mailing Address - Street 2:
Mailing Address - City:MANALAPAN
Mailing Address - State:NJ
Mailing Address - Zip Code:07726-3506
Mailing Address - Country:US
Mailing Address - Phone:732-614-7907
Mailing Address - Fax:
Practice Address - Street 1:2625 E 14TH ST
Practice Address - Street 2:200
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3979
Practice Address - Country:US
Practice Address - Phone:718-769-2698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1107435174400000X
174400000X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator