Provider Demographics
NPI:1174238653
Name:VICTOR, BLONDIE DEMOSTHENE (AGNP)
Entity type:Individual
Prefix:
First Name:BLONDIE
Middle Name:DEMOSTHENE
Last Name:VICTOR
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:BLONDIE
Other - Middle Name:
Other - Last Name:DEMOSTHENE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGNP
Mailing Address - Street 1:11748 ALBATROSS LN
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33569-6300
Mailing Address - Country:US
Mailing Address - Phone:803-727-5850
Mailing Address - Fax:
Practice Address - Street 1:11748 ALBATROSS LN
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33569-6300
Practice Address - Country:US
Practice Address - Phone:803-727-5850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11019797363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty