Provider Demographics
NPI:1457866741
Name:WAYNE, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:WAYNE
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 1:5015 HANNEGAN RD
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-9754
Mailing Address - Country:US
Mailing Address - Phone:360-398-2582
Mailing Address - Fax:
Practice Address - Street 1:5015 HANNEGAN RD
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-9754
Practice Address - Country:US
Practice Address - Phone:360-398-2582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-07
Last Update Date:2017-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA753492376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376G00000XNursing Service Related ProvidersNursing Home AdministratorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA753492Medicaid
WA753492OtherADULT FAMILY HOME