Provider Demographics
NPI:1144603721
Name:DELVA, MARISLENE
Entity Type:Individual
Prefix:
First Name:MARISLENE
Middle Name:
Last Name:DELVA
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 1:11352 GABRIEL STREET
Mailing Address - Street 2:
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174
Mailing Address - Country:US
Mailing Address - Phone:313-575-8111
Mailing Address - Fax:
Practice Address - Street 1:25420 GODDARD ROAD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180
Practice Address - Country:US
Practice Address - Phone:313-388-1666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-01
Last Update Date:2015-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601007382363A00000X
FL9108647363A00000X
NY018640-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant