Provider Demographics
NPI:1154854214
Name:DELOS REYES, CONCEPCION
Entity Type:Individual
Prefix:
First Name:CONCEPCION
Middle Name:
Last Name:DELOS REYES
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 1:14121 PARKE LONG CT
Mailing Address - Street 2:SUITE 201
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-1647
Mailing Address - Country:US
Mailing Address - Phone:832-760-8068
Mailing Address - Fax:
Practice Address - Street 1:14121 PARKE LONG CT
Practice Address - Street 2:SUITE 201
Practice Address - City:CHANTILLY
Practice Address - State:VA
Practice Address - Zip Code:20151-1647
Practice Address - Country:US
Practice Address - Phone:832-760-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133466363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily