Provider Demographics
NPI:1033660360
Name:DALLEAVE, NATHAN IAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:IAN
Last Name:DALLEAVE
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 1:1243 LANIER RD
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-5211
Mailing Address - Country:US
Mailing Address - Phone:336-437-5392
Mailing Address - Fax:
Practice Address - Street 1:1243 LANIER RD
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-5211
Practice Address - Country:US
Practice Address - Phone:336-437-5392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC03479314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility