Provider Demographics
NPI:1235003096
Name:VICKERSTAFF, VICTORIA ALEXANDRIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ALEXANDRIA
Last Name:VICKERSTAFF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12110 LEEILA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44135-4720
Mailing Address - Country:US
Mailing Address - Phone:216-484-3209
Mailing Address - Fax:
Practice Address - Street 1:12110 LEEILA AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44135-4720
Practice Address - Country:US
Practice Address - Phone:216-484-3209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH253Z00000X, 261QH0100X, 320600000X, 331L00000X, 332BN1400X, 332BX2000X, 347E00000X, 374U00000X, 376K00000X, 385H00000X, 373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No253Z00000XAgenciesIn Home Supportive Care
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No331L00000XSuppliersBlood Bank
No332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
No332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No347E00000XTransportation ServicesTransportation Broker
No374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
No385H00000XRespite Care FacilityRespite Care