Provider Demographics
NPI:1194477513
Name:MIMS, VICTORIA HARRISON (FNP-C)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:HARRISON
Last Name:MIMS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1200
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-1200
Mailing Address - Country:US
Mailing Address - Phone:800-640-3451
Mailing Address - Fax:
Practice Address - Street 1:1857 WOODDALE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1510
Practice Address - Country:US
Practice Address - Phone:800-640-3451
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-26
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA224005363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner