Provider Demographics
NPI:1982865374
Name:DELLY, IMELDA
Entity Type:Individual
Prefix:
First Name:IMELDA
Middle Name:
Last Name:DELLY
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 1:1137 BROOKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1805
Mailing Address - Country:US
Mailing Address - Phone:631-242-7472
Mailing Address - Fax:
Practice Address - Street 1:100 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:NESCONSET
Practice Address - State:NY
Practice Address - Zip Code:11767-1749
Practice Address - Country:US
Practice Address - Phone:631-361-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342378021205E367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered