Provider Demographics
NPI:1659357705
Name:VALLONESHIMKO, LAURIE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:
Last Name:VALLONESHIMKO
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32067-0505
Mailing Address - Country:US
Mailing Address - Phone:904-269-7751
Mailing Address - Fax:
Practice Address - Street 1:1626 SHEFFIELD PL
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5268
Practice Address - Country:US
Practice Address - Phone:904-269-7751
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2013-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT0014414174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL675795996OtherMEDWAIVER PROVIDER NUMBER
FL885134400Medicaid
FLK9629Medicare ID - Type Unspecified