=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710034806
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA-MARIE MALAZARTE VENERACION-YUMUL M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/04/2007
-----------------------------------------------------
Last Update Date | 02/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1409 KINGSLEY AVE STE 9E
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-4537
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-215-4151
-----------------------------------------------------
Fax | 904-215-4165
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1118 GREEN PINE CIR
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32065-2567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-282-8079
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | ME92819
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | ME92819
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------