Basic Information
| Provider Information | |||||||||
| NPI: | 1861021420 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TREBOSCHI | ||||||||
| OtherFirstName: | VICTORIA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1712 S 28TH PL | ||||||||
| Address2: | |||||||||
| City: | ROGERS | ||||||||
| State: | AR | ||||||||
| PostalCode: | 727581479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4500 N SHALLOWFORD RD | ||||||||
| Address2: | |||||||||
| City: | DUNWOODY | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303386476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4047786920 | ||||||||
| FaxNumber: | 4047786811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2020 | ||||||||
| LastUpdateDate: | 04/06/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.