Provider Demographics
NPI:1225152978
Name:DELVALLE, LEILANI J
Entity Type:Individual
Prefix:
First Name:LEILANI
Middle Name:J
Last Name:DELVALLE
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 1:6200 SW 73RD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33143-4679
Mailing Address - Country:US
Mailing Address - Phone:786-662-8429
Mailing Address - Fax:786-662-8429
Practice Address - Street 1:6200 SW 73RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33143-4679
Practice Address - Country:US
Practice Address - Phone:786-662-8429
Practice Address - Fax:786-662-8429
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME68841363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU5208AMedicare ID - Type Unspecified