Provider Demographics
NPI:1508138660
Name:DELOACH, MARIE TALLENT (MT(ASCP))
Entity Type:Individual
Prefix:MS
First Name:MARIE
Middle Name:TALLENT
Last Name:DELOACH
Suffix:
Gender:F
Credentials:MT(ASCP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:500 NORTH MUNDO
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528-0187
Mailing Address - Country:US
Mailing Address - Phone:575-759-7252
Mailing Address - Fax:575-759-3532
Practice Address - Street 1:500 NORTH MUNDO
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-7252
Practice Address - Fax:575-759-3532
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC03671395246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B