Provider Demographics
NPI:1760838585
Name:REYES, LETICIA DEDUMO (NPC)
Entity Type:Individual
Prefix:
First Name:LETICIA
Middle Name:DEDUMO
Last Name:REYES
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 504576
Mailing Address - Street 2:
Mailing Address - City:SAIPAN
Mailing Address - State:MP
Mailing Address - Zip Code:96950-8901
Mailing Address - Country:US
Mailing Address - Phone:670-285-1805
Mailing Address - Fax:
Practice Address - Street 1:KULOT DRIVE CHALAN KAMOA
Practice Address - Street 2:
Practice Address - City:SAIPAN
Practice Address - State:MP
Practice Address - Zip Code:96950-8901
Practice Address - Country:US
Practice Address - Phone:670-285-1805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MPF0216740363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily