Provider Demographics
NPI:1871131805
Name:VIVEEN, VICTORIA DIANE (PA-C)
Entity type:Individual
Prefix:MS
First Name:VICTORIA
Middle Name:DIANE
Last Name:VIVEEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5159 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-4931
Mailing Address - Country:US
Mailing Address - Phone:773-434-9216
Mailing Address - Fax:
Practice Address - Street 1:5159 S ASHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60609-4931
Practice Address - Country:US
Practice Address - Phone:773-434-9216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-20
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007475363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant