Provider Demographics
NPI:1114609914
Name:DELACRUZ, DAISY NICOLE (MC- PSS)
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:NICOLE
Last Name:DELACRUZ
Suffix:
Gender:F
Credentials:MC- PSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 N PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93728-2434
Mailing Address - Country:US
Mailing Address - Phone:559-899-0888
Mailing Address - Fax:
Practice Address - Street 1:1040 N PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93728-2434
Practice Address - Country:US
Practice Address - Phone:559-899-0888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-02
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
CAMPSSVJIZGR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker