Provider Demographics
NPI:1710440946
Name:VICTOR, EDITH KAWIRA
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:KAWIRA
Last Name:VICTOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EDITH
Other - Middle Name:KAWIRA
Other - Last Name:MUTHAMIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13461 SHADY KNOLL DR
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3199
Mailing Address - Country:US
Mailing Address - Phone:909-275-5038
Mailing Address - Fax:
Practice Address - Street 1:13461 SHADY KNOLL DR
Practice Address - Street 2:
Practice Address - City:EASTVALE
Practice Address - State:CA
Practice Address - Zip Code:92880-3199
Practice Address - Country:US
Practice Address - Phone:909-275-5038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN279001164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse