Basic Information
| Provider Information | |||||||||
| NPI: | 1275573487 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VALLETTA | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 911 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | TRENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326933239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524632374 | ||||||||
| FaxNumber: | 3524634507 | ||||||||
| Practice Location | |||||||||
| Address1: | 2010 N YOUNG BLVD | ||||||||
| Address2: | |||||||||
| City: | CHIEFLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326261951 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3524632374 | ||||||||
| FaxNumber: | 3524634507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 09/08/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | ME90984 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 270589300 | 05 | FL | MEDICAID |