Provider Demographics
NPI:1255058970
Name:DELOATCH, SHALETHA
Entity type:Individual
Prefix:
First Name:SHALETHA
Middle Name:
Last Name:DELOATCH
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 1:815 N HOMESTEAD BLVD # 205
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030-5024
Mailing Address - Country:US
Mailing Address - Phone:786-584-8800
Mailing Address - Fax:
Practice Address - Street 1:30341 SW 157TH AVE
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-3518
Practice Address - Country:US
Practice Address - Phone:786-584-8800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-24
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier