Provider Demographics
NPI:1821103755
Name:MANCKE, VICTORIA L (APRN-BC, FNP)
Entity Type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:L
Last Name:MANCKE
Suffix:
Gender:F
Credentials:APRN-BC, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15702 W BAKER RD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-9641
Mailing Address - Country:US
Mailing Address - Phone:815-478-4455
Mailing Address - Fax:
Practice Address - Street 1:2025S CHICAGO ST
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60436
Practice Address - Country:US
Practice Address - Phone:815-726-2200
Practice Address - Fax:314-536-8783
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005029363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily