Provider Demographics
NPI:1982231403
Name:VALLELY, JAXON
Entity Type:Individual
Prefix:
First Name:JAXON
Middle Name:
Last Name:VALLELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 CLOVER LN APT A
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-2055
Mailing Address - Country:US
Mailing Address - Phone:267-247-2295
Mailing Address - Fax:
Practice Address - Street 1:358 MOWBRAY ARCH, SUITE #203/205
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507
Practice Address - Country:US
Practice Address - Phone:757-668-7249
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-25
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program