Provider Demographics
NPI:1386699262
Name:MANIGAULT, VICTORIA (CPNP)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:MANIGAULT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:533 CARTERS GRV
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29414-9015
Mailing Address - Country:US
Mailing Address - Phone:843-769-6297
Mailing Address - Fax:843-746-3814
Practice Address - Street 1:4050 BRIDGE VIEW DR
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8415
Practice Address - Country:US
Practice Address - Phone:843-746-3834
Practice Address - Fax:843-746-3814
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1539363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics