Provider Demographics
NPI:1164170726
Name:FORMOSA, VICTORIA
Entity type:Individual
Prefix:MRS
First Name:VICTORIA
Middle Name:
Last Name:FORMOSA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:381 RIVERSIDE DRIVE
Mailing Address - Street 2:SUITE 460
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37064-9000
Mailing Address - Country:US
Mailing Address - Phone:615-224-9800
Mailing Address - Fax:615-224-9840
Practice Address - Street 1:381 RIVERSIDE DRIVE
Practice Address - Street 2:SUITE 460
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37064-9000
Practice Address - Country:US
Practice Address - Phone:615-224-9800
Practice Address - Fax:615-224-9840
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-14
Last Update Date:2024-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN206897163WP0808X
TN35203363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health