Provider Demographics
NPI:1134826712
Name:AMAZING VICTORY LLC
Entity type:Organization
Organization Name:AMAZING VICTORY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAROSE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:475-500-2334
Mailing Address - Street 1:1201 KINGS HWY STE 2
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5319
Mailing Address - Country:US
Mailing Address - Phone:475-500-2334
Mailing Address - Fax:
Practice Address - Street 1:1201 KINGS HWY STE 2
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5319
Practice Address - Country:US
Practice Address - Phone:475-500-2334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-14
Last Update Date:2023-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty