Basic Information
| Provider Information | |||||||||
| NPI: | 1881140036 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NALLEY | ||||||||
| FirstName: | SANDRA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2033 COVE TRL | ||||||||
| Address2: | |||||||||
| City: | WINTER PARK | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327891158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6107640554 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 W BROADWAY ST STE 214 | ||||||||
| Address2: | |||||||||
| City: | OVIEDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327659262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073595693 | ||||||||
| FaxNumber: | 4077925693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2016 | ||||||||
| LastUpdateDate: | 09/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA13092 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 018695300 | 05 | FL | MEDICAID |