Provider Demographics
NPI:1043761117
Name:BALOGUN, VICTORIA RANTI (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:RANTI
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:OLUWARANTI
Other - Last Name:OGUNTOBA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:4192 POLARIS AVE
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-1250
Mailing Address - Country:US
Mailing Address - Phone:864-551-5536
Mailing Address - Fax:
Practice Address - Street 1:4192 POLARIS AVE
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-1250
Practice Address - Country:US
Practice Address - Phone:864-551-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-24
Last Update Date:2025-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016572363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner