Provider Demographics
NPI:1952393225
Name:HARNESS, VICTORIA L (DO)
Entity Type:Individual
Prefix:DR
First Name:VICTORIA
Middle Name:L
Last Name:HARNESS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:L
Other - Last Name:CLEMENTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 N BARKER ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-4587
Mailing Address - Country:US
Mailing Address - Phone:706-982-2721
Mailing Address - Fax:828-321-3211
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-671-5000
Practice Address - Fax:828-321-3211
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-00361208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2014-00361OtherBOARD OF MEDICINE
NC1952393225Medicaid
GA438111OtherWELLCARE
GA11D1083186OtherCLIA ID
BH7409356OtherDEA
GA060358OtherPHYSICIAN LICENSE
GA829645739AMedicaid
GA060358OtherPHYSICIAN LICENSE