Individual
MALLORY ANNE VENTSAM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
511 66TH ST N, ST PETERSBURG, FL 33710-6939
(727) 498-8544
Mailing address
12627 PORTMARNOCK DR, ODESSA, FL 33556-5416
(813) 787-4317
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
—
—
Other
Enumeration date
07/11/2013
Last updated
07/11/2013
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