Provider Demographics
NPI:1164792289
Name:VAILE, MARYDEE LYNN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARYDEE
Middle Name:LYNN
Last Name:VAILE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 PLANTATION ISLAND DR S
Mailing Address - Street 2:SUITE 230
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-3113
Mailing Address - Country:US
Mailing Address - Phone:202-821-3097
Mailing Address - Fax:
Practice Address - Street 1:11740-2 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-1629
Practice Address - Country:US
Practice Address - Phone:904-880-5755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-05
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH10423111N00000X
SC3682111N00000X
CT001892111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor