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General NPI Number Information
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NPI Number | 1659357705
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Entity Type | Individual
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Provider Name | LAURIE VALLONESHIMKO MPT
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Gender | Female
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Dates
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Enumeration Date | 12/21/2005
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Last Update Date | 11/27/2013
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Provider Practice Location Address
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Address Line | 1626 SHEFFIELD PL
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City | ORANGE PARK
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State | FL
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Zip | 32073-5268
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Country | US
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Telephone | 904-269-7751
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 505
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City | ORANGE PARK
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State | FL
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Zip | 32067-0505
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Country | US
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Telephone | 904-269-7751
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | PT0014414
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License Number State | FL
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