Provider Demographics
NPI:1609416304
Name:WARREN, DELFANITA ELLEN (HAIR LOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:DELFANITA
Middle Name:ELLEN
Last Name:WARREN
Suffix:
Gender:F
Credentials:HAIR LOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 CRANDON AVE
Mailing Address - Street 2:
Mailing Address - City:CALUMET CITY
Mailing Address - State:IL
Mailing Address - Zip Code:60409-2202
Mailing Address - Country:US
Mailing Address - Phone:708-299-6046
Mailing Address - Fax:
Practice Address - Street 1:16060 OAK PARK AVE STE 151
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-1626
Practice Address - Country:US
Practice Address - Phone:708-316-1630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-10
Last Update Date:2020-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies