1326279167 NPI number — KEISHA TRACEY DELVA

Table of content: KEISHA TRACEY DELVA (NPI 1326279167)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326279167 NPI number — KEISHA TRACEY DELVA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DELVA
Provider First Name:
KEISHA
Provider Middle Name:
TRACEY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326279167
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1485 S. SEMORAN BLVD., WINTER PARK, FL 32792
Provider Second Line Business Mailing Address:
SUITE 1402
Provider Business Mailing Address City Name:
WINTER PARK
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32792-5533
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
321-397-3000
Provider Business Mailing Address Fax Number:
407-681-5478

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1485 S. SEMORAN BLVD., WINTER PARK, FL 32792
Provider Second Line Business Practice Location Address:
SUITE 1402
Provider Business Practice Location Address City Name:
WINTER PARK
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32792-5533
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
321-397-3000
Provider Business Practice Location Address Fax Number:
407-681-5478
Provider Enumeration Date:
07/28/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)