Provider Demographics
NPI:1235491457
Name:ETIENNE VAVAL, GERDA (MSED)
Entity Type:Individual
Prefix:
First Name:GERDA
Middle Name:
Last Name:ETIENNE VAVAL
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 NASSAU AVE
Mailing Address - Street 2:310 NASSAU AVENUE
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-6119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 NASSAU AVE
Practice Address - Street 2:310 NASSAU AVENUE
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-6119
Practice Address - Country:US
Practice Address - Phone:516-378-4977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY174400000XSPECIALISTOtherOTHER SERVICE PROVIDER