Provider Demographics
NPI:1295509784
Name:VICTORIN, MARIE SHERLY
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:SHERLY
Last Name:VICTORIN
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 1:459 PASSAIC AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-7457
Mailing Address - Country:US
Mailing Address - Phone:908-800-3974
Mailing Address - Fax:
Practice Address - Street 1:65 ROYAL DR APT 224
Practice Address - Street 2:
Practice Address - City:PISCATAWAY
Practice Address - State:NJ
Practice Address - Zip Code:08854-3488
Practice Address - Country:US
Practice Address - Phone:908-800-3974
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-14
Last Update Date:2024-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14951000363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily