Provider Demographics
NPI:1023259967
Name:HARGRAVE, VICTORIA A (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:A
Last Name:HARGRAVE
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:ANN
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:390 MAPLE SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:JERSEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62052-2000
Mailing Address - Country:US
Mailing Address - Phone:618-498-7518
Mailing Address - Fax:618-498-3052
Practice Address - Street 1:390 MAPLE SUMMIT RD
Practice Address - Street 2:
Practice Address - City:JERSEYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62052-2000
Practice Address - Country:US
Practice Address - Phone:618-498-2101
Practice Address - Fax:618-498-8153
Is Sole Proprietor?:No
Enumeration Date:2009-03-22
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL277002358363LF0000X, 363LP0808X
IL041347129163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL277002358OtherIL FPA APRN LICENSE