Basic Information
| Provider Information | |||||||||
| NPI: | 1689052698 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCGILLIS | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | |||||||||
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| Credential: | FNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 325 E M 55 STE B | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487638211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893626426 | ||||||||
| FaxNumber: | 9893626527 | ||||||||
| Practice Location | |||||||||
| Address1: | 325 E M 55 STE B | ||||||||
| Address2: | |||||||||
| City: | TAWAS CITY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9893626426 | ||||||||
| FaxNumber: | 9893626527 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2015 | ||||||||
| LastUpdateDate: | 04/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704244691 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 4704244691 | 01 | MI | LICENSE | OTHER |