Provider Demographics
NPI:1346996246
Name:DEL VALLE, WAVERLY ELYSSE (PA-C)
Entity Type:Individual
Prefix:
First Name:WAVERLY
Middle Name:ELYSSE
Last Name:DEL VALLE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:888-938-3838
Mailing Address - Fax:888-919-1083
Practice Address - Street 1:1125 SOUTH BLVD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2812
Practice Address - Country:US
Practice Address - Phone:888-938-3838
Practice Address - Fax:888-919-0183
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-01
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085009149363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant