Provider Demographics
NPI:1356975916
Name:SKLAVOS, VICTORIA (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:SKLAVOS
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36433 BAGDAD DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48312-3012
Mailing Address - Country:US
Mailing Address - Phone:248-410-3495
Mailing Address - Fax:
Practice Address - Street 1:21844 23 MILE RD
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-4422
Practice Address - Country:US
Practice Address - Phone:586-598-8115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-23
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704301101363LP2300X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1627723Medicaid