Provider Demographics
NPI:1114397304
Name:DELUCA, MINNA RENA (NP)
Entity Type:Individual
Prefix:
First Name:MINNA
Middle Name:RENA
Last Name:DELUCA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MINNA
Other - Middle Name:RENA
Other - Last Name:SHEBLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1508 TOMBRAS AVE
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-2720
Mailing Address - Country:US
Mailing Address - Phone:423-867-4969
Mailing Address - Fax:423-867-4971
Practice Address - Street 1:1508 TOMBRAS AVE
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-2720
Practice Address - Country:US
Practice Address - Phone:423-867-4969
Practice Address - Fax:423-867-4971
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ018240Medicaid
TN103I507980Medicare PIN