Provider Demographics
NPI:1932540416
Name:VENTSAM, MALLORY ANNE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:VENTSAM
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 1:12627 PORTMARNOCK DR
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:FL
Mailing Address - Zip Code:33556-5416
Mailing Address - Country:US
Mailing Address - Phone:813-787-4317
Mailing Address - Fax:
Practice Address - Street 1:511 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-6939
Practice Address - Country:US
Practice Address - Phone:727-498-8544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-11
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist