Provider Demographics
NPI:1578176160
Name:DE LA CRUZ, RACHELLE CAMELLE (PMHNP)
Entity Type:Individual
Prefix:MRS
First Name:RACHELLE
Middle Name:CAMELLE
Last Name:DE LA CRUZ
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14202-2016
Mailing Address - Country:US
Mailing Address - Phone:716-842-0440
Mailing Address - Fax:
Practice Address - Street 1:255 DELAWARE AVE STE 400
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14202-2016
Practice Address - Country:US
Practice Address - Phone:716-842-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF403073-01363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health