Provider Demographics
NPI:1881748952
Name:ROEBUCK, VICTORIA A (WHNP, MSN)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:A
Last Name:ROEBUCK
Suffix:
Gender:F
Credentials:WHNP, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:761 OLD NORCROSS RD
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-4317
Mailing Address - Country:US
Mailing Address - Phone:770-513-4000
Mailing Address - Fax:770-995-3495
Practice Address - Street 1:761 OLD NORCROSS RD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-4317
Practice Address - Country:US
Practice Address - Phone:770-513-4000
Practice Address - Fax:770-995-3495
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN074697363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00850099AMedicaid
GA00850099AOtherWELLCARE
GA000850099AOtherPEACH STATE