Provider Demographics
NPI:1629378427
Name:ST VICTOR, MYRTHA
Entity Type:Individual
Prefix:
First Name:MYRTHA
Middle Name:
Last Name:ST VICTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRTHA
Other - Middle Name:
Other - Last Name:ST VICTOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PRACTICAL NURSE
Mailing Address - Street 1:1259 SE NANCY LN
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-3119
Mailing Address - Country:US
Mailing Address - Phone:772-359-6787
Mailing Address - Fax:
Practice Address - Street 1:1259 SE NANCY LN
Practice Address - Street 2:
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-3119
Practice Address - Country:US
Practice Address - Phone:772-359-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-26
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN 5195617164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse