Provider Demographics
NPI:1568976157
Name:DEMELLO, DESIREE ANGELICA
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:ANGELICA
Last Name:DEMELLO
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 1:14728 GILMORE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411-1511
Mailing Address - Country:US
Mailing Address - Phone:818-270-6010
Mailing Address - Fax:
Practice Address - Street 1:14515 HAMLIN ST
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91411-1608
Practice Address - Country:US
Practice Address - Phone:818-989-7475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-20
Last Update Date:2017-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist