Provider Demographics
NPI:1952833857
Name:BALCOM, VICTORIA (AGPCNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name:BALCOM
Suffix:
Gender:F
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23706 STONELEIGH DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-1951
Mailing Address - Country:US
Mailing Address - Phone:616-318-9786
Mailing Address - Fax:
Practice Address - Street 1:950 VICTORS WAY STE 100
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5217
Practice Address - Country:US
Practice Address - Phone:734-926-4800
Practice Address - Fax:734-973-0595
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704283130363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner