Provider Demographics
NPI:1972393031
Name:JOHNSON, VICTORIA
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 S WAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:VILLA PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60181-3524
Mailing Address - Country:US
Mailing Address - Phone:315-690-1433
Mailing Address - Fax:
Practice Address - Street 1:1330 S WAYSIDE DR
Practice Address - Street 2:
Practice Address - City:VILLA PARK
Practice Address - State:IL
Practice Address - Zip Code:60181-3524
Practice Address - Country:US
Practice Address - Phone:315-690-1433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-10
Last Update Date:2025-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program