Provider Demographics
NPI:1255895017
Name:MANSFIELD, VICTORIA (PA)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MANSFIELD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:
Other - Last Name:CULLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5754
Mailing Address - Country:US
Mailing Address - Phone:901-725-8347
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:2670 MCINGVALE RD STE J
Practice Address - Street 2:
Practice Address - City:HERNANDO
Practice Address - State:MS
Practice Address - Zip Code:38632-8696
Practice Address - Country:US
Practice Address - Phone:901-259-1600
Practice Address - Fax:901-259-1698
Is Sole Proprietor?:No
Enumeration Date:2019-01-25
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00419363AM0700X, 363AS0400X
TN3785363AS0400X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSPA00419OtherMS LICENSE
TN3785OtherTN LICENSE