Basic Information
| Provider Information | |||||||||
| NPI: | 1275661613 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PANDAK | ||||||||
| FirstName: | VALERI' | ||||||||
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| Credential: | EI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3541 N.W. 24TH BLVD | ||||||||
| Address2: | #107 | ||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523598787 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 111 NATURE WALK PARKWAY SUITE 101 | ||||||||
| Address2: | |||||||||
| City: | ST AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32092 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042307761 | ||||||||
| FaxNumber: | 9042307763 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.