Provider Demographics
NPI:1629409891
Name:DELVECCHIO, DOMINIQUE M (NP)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:M
Last Name:DELVECCHIO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2716 OCEAN PARK BLVD. SUITE 3082
Mailing Address - Street 2:INSTITUTE FOR NERVE MEDICINE
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405
Mailing Address - Country:US
Mailing Address - Phone:310-314-6410
Mailing Address - Fax:310-314-2414
Practice Address - Street 1:2716 OCEAN PARK BLVD. SUITE 3082
Practice Address - Street 2:INSTITUTE FOR NERVE MEDICINE
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405
Practice Address - Country:US
Practice Address - Phone:310-314-6410
Practice Address - Fax:310-314-2414
Is Sole Proprietor?:No
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23581363LG0600X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care