Provider Demographics
NPI:1023570777
Name:DE LA VEGA, CHELISA MARTINEZ
Entity Type:Individual
Prefix:
First Name:CHELISA
Middle Name:MARTINEZ
Last Name:DE LA VEGA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 1/2 CROUCH AVE
Mailing Address - Street 2:
Mailing Address - City:DEVINE
Mailing Address - State:TX
Mailing Address - Zip Code:78016-2026
Mailing Address - Country:US
Mailing Address - Phone:210-330-4955
Mailing Address - Fax:
Practice Address - Street 1:8600 WURZBACH RD STE 700
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-4332
Practice Address - Country:US
Practice Address - Phone:210-737-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-02
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX345773164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse