Provider Demographics
NPI:1902413636
Name:WALDEN, DELESA SHANA KAY
Entity Type:Individual
Prefix:
First Name:DELESA
Middle Name:SHANA KAY
Last Name:WALDEN
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 1:1900 TOLBERT TER APT 104
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23836-2823
Mailing Address - Country:US
Mailing Address - Phone:954-982-4985
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-9274
Practice Address - Country:US
Practice Address - Phone:804-765-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-27
Last Update Date:2020-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024180176363LF0000X
VA0001268158163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily