Provider Demographics
NPI:1922198662
Name:VESTAL, VICTORIA MARGARET (LPTBD)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:MARGARET
Last Name:VESTAL
Suffix:
Gender:F
Credentials:LPTBD
Other - Prefix:MISS
Other - First Name:VICTORIA
Other - Middle Name:MARGARET
Other - Last Name:LOOMIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPTBS
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624
Mailing Address - Country:US
Mailing Address - Phone:503-791-1805
Mailing Address - Fax:360-642-3408
Practice Address - Street 1:316 1ST AVE NORTH
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624
Practice Address - Country:US
Practice Address - Phone:360-642-8551
Practice Address - Fax:360-642-3408
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0865225100000X
WAPT00003498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR130238Medicaid
WA8334625Medicaid
OR130238Medicaid
WA8856619Medicare ID - Type Unspecified