Provider Demographics
NPI:1922671825
Name:GONGORA, VALANCY E
Entity Type:Individual
Prefix:
First Name:VALANCY
Middle Name:E
Last Name:GONGORA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VALANCY
Other - Middle Name:E
Other - Last Name:GONGORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1553 N REDHAWK DR
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-6363
Mailing Address - Country:US
Mailing Address - Phone:419-705-0129
Mailing Address - Fax:
Practice Address - Street 1:1553 N REDHAWK DR
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-6363
Practice Address - Country:US
Practice Address - Phone:419-705-0129
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-20
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor