Provider Demographics
NPI:1245218528
Name:DELUCIA, MARY CATHERINE (WHCNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:CATHERINE
Last Name:DELUCIA
Suffix:
Gender:F
Credentials:WHCNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:CATHERINE
Other - Last Name:PELAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1640 FORT ST
Mailing Address - Street 2:SUITE D ATTN: DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-2040
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:15675 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2334
Practice Address - Country:US
Practice Address - Phone:734-282-3600
Practice Address - Fax:734-282-3603
Is Sole Proprietor?:No
Enumeration Date:2006-01-06
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704127749363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H28865OtherBLUE CROSS
1144634403OtherGROUP NPI HENRY FORD WYANDOTTE
MIQ24657080Medicare PIN