Provider Demographics
NPI:1720112972
Name:VILLAFANE, MAYOMY ANNETTE (ST)
Entity Type:Individual
Prefix:
First Name:MAYOMY
Middle Name:ANNETTE
Last Name:VILLAFANE
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11523 NW 6TH CT
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33071-4117
Mailing Address - Country:US
Mailing Address - Phone:954-753-7650
Mailing Address - Fax:954-753-7650
Practice Address - Street 1:11523 NW 6TH CT
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33071-4117
Practice Address - Country:US
Practice Address - Phone:954-753-7650
Practice Address - Fax:954-753-7650
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146005537235Z00000X
FLSA4456235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000546300Medicaid
FL000259200Medicaid
IL103034Medicaid
FL000259200Medicaid