Provider Demographics
NPI:1851939979
Name:DIMPUDUS, DELISA ALMA
Entity Type:Individual
Prefix:
First Name:DELISA
Middle Name:ALMA
Last Name:DIMPUDUS
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 1:1325 E COOLEY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3966
Mailing Address - Country:US
Mailing Address - Phone:909-204-7860
Mailing Address - Fax:
Practice Address - Street 1:1325 E COOLEY DR STE 101
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3966
Practice Address - Country:US
Practice Address - Phone:909-204-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-19
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013566363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily