MEDICARE: MAYOMY ANNETTE VILLAFANE ST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	146005537	IL
2	235Z00000X	Speech-Language Pathologist	SA4456	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720112972
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAYOMY ANNETTE VILLAFANE ST

Provider Business Mailing Address
First Line	:	11523 NW 6TH CT
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-4117
Country	:	US
Telephone Number	:	954-753-7650
Fax Number	:	954-753-7650

Provider Business Practice Location Address
First Line	:	11523 NW 6TH CT
Second Line	:
City	:	CORAL SPRINGS
State	:	FL
Zip	:	33071-4117
Country	:	US
Telephone Number	:	954-753-7650
Fax Number	:	954-753-7650

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	04/20/2011

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Directions to “ MAYOMY ANNETTE VILLAFANE ST” Practice Location

Language	Start Address	Practice Location

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