Provider Demographics
NPI:1629407382
Name:DEZONIA, GLADYS
Entity Type:Individual
Prefix:
First Name:GLADYS
Middle Name:
Last Name:DEZONIA
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 1:8600 STARBOARD DR
Mailing Address - Street 2:A1052
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-3431
Mailing Address - Country:US
Mailing Address - Phone:760-207-2068
Mailing Address - Fax:
Practice Address - Street 1:8600 STARBOARD DR
Practice Address - Street 2:A1052
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-3431
Practice Address - Country:US
Practice Address - Phone:760-207-2068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner