Provider Demographics
NPI:1730735473
Name:SUPPLICE, VALLLERY
Entity type:Individual
Prefix:MR
First Name:VALLLERY
Middle Name:
Last Name:SUPPLICE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 SHERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07114-1650
Mailing Address - Country:US
Mailing Address - Phone:770-940-7390
Mailing Address - Fax:
Practice Address - Street 1:218 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07114-1650
Practice Address - Country:US
Practice Address - Phone:770-940-7390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator