Basic Information
| Provider Information | |||||||||
| NPI: | 1629419858 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SIDELL | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | FELLOWES | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FELLOWES | ||||||||
| OtherFirstName: | VICTORIA | ||||||||
| OtherMiddleName: | ELISABETH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 445 CHARLES H DIMMOCK PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045201764 | ||||||||
| FaxNumber: | 8667813220 | ||||||||
| Practice Location | |||||||||
| Address1: | 445 CHARLES H DIMMOCK PKWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | COLONIAL HEIGHTS | ||||||||
| State: | VA | ||||||||
| PostalCode: | 238342970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8045201764 | ||||||||
| FaxNumber: | 8667813220 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2013 | ||||||||
| LastUpdateDate: | 09/08/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 0024170588 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.