Provider Demographics
NPI:1417659764
Name:VALLEJO, ATHENA MICHELLE
Entity Type:Individual
Prefix:
First Name:ATHENA
Middle Name:MICHELLE
Last Name:VALLEJO
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 1:1850 LAFAYETTE AVE APT 21E
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10473-2841
Mailing Address - Country:US
Mailing Address - Phone:917-935-1353
Mailing Address - Fax:
Practice Address - Street 1:1850 LAFAYETTE AVE APT 21E
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10473-2841
Practice Address - Country:US
Practice Address - Phone:917-935-1353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-20
Last Update Date:2023-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program