Provider Demographics
NPI:1922743806
Name:CARRINGTON, VALENCIA
Entity Type:Individual
Prefix:
First Name:VALENCIA
Middle Name:
Last Name:CARRINGTON
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 1:1314 W LA SALLE CT
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4412
Mailing Address - Country:US
Mailing Address - Phone:141-482-8810
Mailing Address - Fax:
Practice Address - Street 1:1314 W LA SALLE CT
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4412
Practice Address - Country:US
Practice Address - Phone:141-482-8810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-04
Last Update Date:2023-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI87-4202764Medicaid